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Supplemental Questionnaire

Last Name
First Name

 

2324 NURSE SUPERVISOR
SPECIALTY: LONG TERM CARE/GERIATRICS
SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine if you meet the minimum qualifications of a 2324 Nurse Supervisor in the Long Term Care/Geriatrics 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.


1A.

What is the highest degree you have obtained in Nursing?

Associate's of Science Degree in Nursing (ASN)
Bachelor's of Science Degree in Nursing (BSN)
Master's of Science Degree in Nursing (MSN) or higher (i.e. PhD.)
No Degree in Nursing
1B.

Please list the school where you obtained your degree in Nursing. If you do not possess any of the degrees identified above, type N/A.

2A.

Please identify the highest graduate level degree that you possess from the list of disciplines below. If you do not have a graduate level degree in these disciplines, please select "None of the above." 

Master's degree in Nursing
Master's degree in Public Health
Master's degree in Public Administration
Ph.D. degree in Nursing
Ph.D. degree in Public Health
Ph.D. degree in Public Administration
None of the above
2B.

Please list the school(s) where you obtained your Advanced Degree. If you do not possess any of the degrees identified above, type N/A.

3A.

Do you possess a valid California Registered Nurse license issued by the California Board of Registered Nursing?

Yes No
3B.

If you answered “Yes” to question 3A. above, please provide your California Registered Nurse license number, your name as it appears on your Registered Nurse license, and the expiration date of your license.  If you answered “No” to question 3A. above, please provide an explanation below.

4A.

Do you have a valid Cardiopulmonary Resuscitation (CPR) certificate issued by the American Heart Association (AHA)?

Yes No
4B.

If you answered “Yes” to question 4A. above, please identify all of the valid AHA CPR certificates that you possess. 

Basic Life Support (BLS) for Healthcare Providers
Advanced Cardiovascular Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
Other
4C.

If you answered “No” or “Other” to questions 4A. or 4B. above, please provide an explanation below.

5A.

How much full-time equivalent experience do you have in a designated nursing supervisory capacity (nurse manager or designated charge nurse) or administrative leadership/support role in a skilled nursing facility, long term care, rehabilitation setting, or other acute care setting focusing on managment of chronic diseases, geriatric, and rehab care?

I do not have any experience in these areas
I have some, but less than 24 months of experience in these areas
I have between 24 months and 35 months of experience in these areas
I have between 36 months and 47 months of experience in these areas
I have between 48 months and 59 months of experience in these areas
I have more than 60 months of experience in these areas
5B.

In accordance with your response to question 5A. above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) where you obtained the verifiable full-time equivalent work experience.

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.  Do not type - See Resume. If you do not have experience in these areas, please type N/A.

5C.

In accordance with your responses to questions 5A. and 5B. above, please provide a brief description of your qualifying work experience and include in your answer your specific role and primary duties and responsibilities. Do not type - See Resume. If you do not have experience in these areas, please type N/A.

6A.

In accordance with your response to question 5A. above, how many employees do you have experience supervising?  Relevant supervisory experience should include, but not be limited to staff development, performance evaluation, and disciplinary processes. 

I have experience supervising fewer than 25 employees
I have experience supervising between 25 to 49 employees
I have experience supervising between 50 to 74 employees
I have experience supervising between 75 to 100 employees
I have experience supervising more than 100 employees
 

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.

The Joint Commission.
California Code of Regulations - Title 22.
Centers for Medicare & Medicaid Services.
Americans with Disabilities Act (ADA).
Equal Employment Opportunity Commission (EEOC).
I do not have knowledge or experience in these areas.
 

I understand that checking this box will serve as my electronic signature. I certify that I am the author of this form and all information presented is true and based upon my work education and/or work experience. I understand that prior to an appointment, I may be required to provide written verification of any of the information provided above and, during the probationary period, I may be required by the hiring department to participate in (a) performance test(s). I further understand that any false, incomplete, or incorrect statement may result in disqualification, dismissal, or termination of employment from the City and County of San Francisco.