Department of Human Resources

2322 NURSE MANAGER
SPECIALTY: Quality Management
SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine if you meet the minimum qualifications of a 2322 Nurse Manager in the Quality Management Nursing specialty, and to determine your knowledge, skills, and abilities in job-related areas that have been identified as critical for satisfactory performance in this specialty.

Responses to supplemental questionnaire items must be supported by the information provided in the body of your application (i.e. education and training/employment record section) in order to receive appropriate credit, and are subject to verification. Verification of experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the selection process.

INSTRUCTIONS: Please answer all applicable questions by choosing the best response that matches your education, experience, certifications, licenses, and/or by providing the information requested.

Do you possess a valid permanent/temporary (including interim permit) California Registered Nurse License issued by the California Board of Registered Nursing?

If you answered "Yes" to Question 1A., please provide your California Registered Nurse License number, your name as it appears on your License, and the expiration date of your License. If you answered "No" to Question 1A., please provide additional information below.

What is the highest level of education that you have completed?

What additional advanced degrees do you have?

If you selected "Other" in question 3A., please specify below.

Which of the following valid American Heart Association Cardiopulmonary Resuscitation (CPR) Certificates do you possess?

Please provide your name and the expiration date for each of the American Heart Association CPR Certificates you selected in Question 4A. If you answered "None of the above" to question 4A., please provide an explanation.

Which of the following electronic medical records software systems do you have experience using?

If you selected "Other" in question 5A., please specify below.

Do you have knowledge and experience in the application of the following federal and state regulatory and/or accreditation standards? If yes, please select all that apply.

Referring to your answer in question 6A., please indicate the tasks or duties you have performed that required the application of the regulations and accreditation standards you selected in question 6A.

How much verifiable full-time equivalent work experience do you have in Nursing Quality Management, Nursing Quality Improvement, or Utilization Management in an acute care hospital, clinic, home health agency or other health care setting? (Full-time experience is equivalent to 40 hours per week.)

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 7A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected "No experience," please type N/A.

Do not type “See Resume.”

Referring to your answers in questions 7A. and 7B., please provide a brief description of your verifiable work experience as indicated in questions 7A. and 7B. In your answer, include details about your specific role, your primary duties, and your responsibilities. If selected "No experience," please type N/A.

Do not type “See Resume.”

How much verifiable full-time equivalent work experience do you have implementing a Lean program in a hospital setting? (Full-time experience is equivalent to 40 hours per week.)

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 8A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected "No experience," please type N/A.

Do not type “See Resume.”

Referring to your answers in questions 8A. and 8B., please provide a brief description of your verifiable work experience as indicated in questions 8A. and 8B. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you selected "No experience," please type N/A.

Do not type “See Resume.”

How much full-time equivalent work experience do you have supervising in a health care setting? (Full-time experience is equivalent to 40 hours per week.)

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your full-time equivalent work experience as indicated in question 9A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected "No experience," please type N/A.

Do not type “See Resume.”

Referring to your answers in questions 9A. and 9B., please provide a brief description of your verifiable work experience as indicated in questions 9A. and 9B. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you selected "No experience," please type N/A.

Do not type “See Resume.”