Official SealDepartment of Human Resources


#CBT-2830-902546
Supplemental Questionnaire

Last Name
First Name

 

2830 Public Health Nurse
SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine if you meet the minimum qualifications of a 2830 Public Health Nurse and to evaluate your work experience, licenses and certifications and desirable qualifications.

Responses to supplemental questionnaire items must be supported by the information provided in the body of your application (i.e., Education, Professional Licenses/Certifications/Registrations, Employment Record sections) in order to receive appropriate credit and are subject to verification. Verification of education, experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the recruitment and selection process.

A resume should NOT be submitted to substitute for a completed application. If you write “See Resume” on the application or on the Supplemental Questionnaire, your application may be rejected.

As a reminder, all qualifying licensure, registrations, certifications  and experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the licensure, registration, certification, and experience you are about to describe in the applicable sections of your application, you will not receive credit. If you are copying an old application, please take the time to update applicable sections before submitting your application.

If you experience technical difficulties, make note of any error messages and contact the analyst before the filing deadline.

 

 

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.

 


1.

Do you have a valid Permanent/Temporary California License as a Registered Nursed Issued by the California Board of Registered Nursing?

As a reminder, please include all licenses/certifications/registrations in the "Professional Licenses, Certifications or Registrations" section of your application in order to receive credit for these licenses/certifications/registrations. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.

Yes No
2.

Do you have a valid Public Health Nurse Certificate issued by the California State Department of Health?

As a reminder, please include all licenses/certifications/registrations in the "Professional Licenses, Certifications or Registrations" section of your application in order to receive credit for these licenses/certifications/registrations. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.

Yes No
3.

Do you have a valid California Driver’s License?

As a reminder, please include all licenses/certifications/registrations in the "Professional Licenses, Certifications or Registrations" section of your application in order to receive credit for these licenses/certifications/registrations. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.

Yes No
4.

How much verifiable full-time equivalent professional work experience do you have in the last five (5) years as a Registered Nurse in an acute care hospital, primary care facility, home health agency, or public health agency? (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some experience, but less than 12 months
At least 12 months, but less than 24 months
24 or more months
5a.

How much verifiable full-time equivalent professional work experience do you have working as a Public Health Nurse? (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some, but less than 12 Months
12 to 23 Months
24 or more Months
5b.

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 5a.

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 that you do not have experience, please type N/A.

Do not type “See Resume.”

5c.

Referring to your answers in questions 5a. and 5b., please provide a brief description of your verifiable work experience as indicated in questions 5a. and 5b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.

Do not type “See Resume.”

6a.

How much verifiable full-time equivalent professional, preceptorship, or volunteer work experience do you have as a health care provider serving a diverse urban population? (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some, but less than 6 Months
6 to 11 Months
12 to 23 Months
24 or more Months
6b.

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 6a.

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 that you do not have experience, please type N/A.

Do not type “See Resume.”

6c.

Referring to your answers in questions 6a. and 6b., please provide a brief description of your verifiable work experience as indicated in questions 6a. and 6b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.

Do not type “See Resume.”

7a.

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

Basic Life Support (BLS) for Healthcare Providers
Advanced Cardiovascular Life Supported (ACLS)
Pediatric Advanced Life Support (PALS)
None of the above
7b.

Please provide your name, Certificate number, and the expiration date for each of the American Heart Association CPR Certificates you selected in Question 7a. If you answered "None of the above" to question 7a., please provide an explanation.

8a.

How much verifiable full-time equivalent professional work experience do you performing activities in Communicable Disease Surveillance? Communicable Disease Surveillance refers to contact tracing, monitoring, and follow up, but not infection control in an acute care setting. (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some, but less than 12 Months
12 to 23 Months
24 or more Months
8b.

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 that you do not have experience, please type N/A.

Do not type “See Resume.”

8c.

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 do not have experience, please type N/A.

Do not type “See Resume.”

9a.

How much full-time equivalent professional work experience do you have providing Case Management in the past 5 years? (Full-time experience is equivalent to 40 hours per week.)

Case management is defined as desktop or home visit case management with a caseload of patients/clients managing health, social services, and referrals. This type of case management is differentiated from utilization review in that the focus of utilization review is to define services that are medically necessary for insurance reimbursement. In addition, this type of case management is differentiated from Home Health Case Management in that the focus extends beyond the physical domain to both health/medical and human services.

No Experience
Some, but less than 12 Months
12 to 23 Months
24 or more Months
9b.

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 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 that you do not have experience, please type N/A.

Do not type “See Resume.”

9c.

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 do not have experience, please type N/A.

Do not type “See Resume.”

10.

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

Associate degree in Nursing (ASN/ADN)
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN) or higher (e.g., PhD in Nursing)
None of the above
11a.

How much verifiable full-time equivalent professional, preceptorship, or volunteer work experience do you have coordinating patient care with community based organizations as part of your care plans? (Full-time experience is equivalent to 40 hours per week.) Coordinating Patient Care with a Community Based Organization refers to linking and referring patients to Human Services and Health Services agencies to ensure continued treatment of the patient.

No Experience
Some, but less than 12 Months
12 to 23 Months
24 or more Months
11b.

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 11a.

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 that you do not have experience, please type N/A.

Do not type “See Resume.”

11c.

Referring to your answers in questions 11a. and 11b., please provide a brief description of your verifiable work experience as indicated in questions 11a. and 11b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.

Do not type “See Resume.”

12a.

Which of the following target populations have you worked with in providing Registered Nurse or Public Health Nurse care?

Geriatric
Adult
Immigrants
Teens
Women and Infants
Children with special needs
Mental Health patients with or without co-occurring substance abuse
Pediatric
Homeless
None of the above
12b.

Please indicate the employers where you gained your experience working with the target populations that you selected in question 12a. Include the employer name, manager(s) name, location, and dates of employment (e.g. MM/YYYY – MM/YYYY). If you selected "None of the above," please type N/A.

13a.

How much verifiable experience do you have as a Public Health Nurse implementing and/or coordinating emergency preparedness, response and recovery efforts?

No Experience
Some, but less than 6 months
6 to 11 Months
12 or More months
13b.

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 13a.

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 that you do not have experience, please type N/A.

Do not type “See Resume.”

13c.

Referring to your answers in questions 13a. and 13b., please provide a brief description of your verifiable work experience as indicated in questions 13a. and 13b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.

Do not type “See Resume.”

14a.

How much verifiable experience do you have as a Public Health Nurse working with community based organizations and community groups?

No Experience
Some, but less than 6 Months
6 to 11 Months
12 or more Months
14b.

Please indicate the employers where you gained your experience working with the target populations that you selected in question 14a. Include the employer name, manager(s) name, location, and dates of employment (e.g. MM/YYYY – MM/YYYY). If you selected "None of the above," please type N/A.

14c.

Referring to your answers in questions 14a. and 14b., please provide a brief description of your verifiable work experience as indicated in questions 14a. and 14b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.

Do not type “See Resume.”

15a.

How much verifiable volunteer/work experience do you have in disaster mitigation, planning and/or recovery with a disaster-based volunteer organization?

No Experience
Some, but less than 6 Months
6 to 11 Months
12 or More Months
15b.

Please provide the name of the employer(s) and the dates of volunteer work/employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable volunteer/work experience as indicated in question 15a.

In addition, please list the name of (a) supervisor(s), manager(s) or volunteer coordinator(s) who can verify the information provided as well as his or her contact information. If you selected that you do not have volunteer/work experience, please type N/A.

Do not type “See Resume.”

15c.

Referring to your answers in questions 15a. and 15b., please provide a brief description of your verifiable volunteer/work experience as indicated in questions 15a. and 15b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have volunteer/work experience, please type N/A.

Do not type “See Resume.”

 

I understand that checking this box will serve as my electronic signature. I certify that I am the author of this questionnaire and all information presented is true and based upon my education, training, skills, and experience. I understand and agree that any information provided is subject to verification. I also understand that any false, incomplete, or incorrect statement may result in disqualification, termination, or dismissal from employment with the City and County of San Francisco.