All applicants are required to complete the Supplemental Questionnaire as part of the online application process. Response cannot be changed or edited after submission. The questionnaire will be used to 1) assess each candidate's possession of the minimum qualifications; and 2) determine each candidate's score on the Training and Experience Evaluation, as described on the examination announcement. Insufficient or non-responsive answers to the Supplemental Questionnaire may result in ineligibility, disqualification, or lower scores.
Responses to items on the Supplemental Questionnaire must be supported by the information provided on the application. This information is subject to verification. Please be sure to include all relevant education, professional licenses, certifications or registrations and work experience in the respective Education, Professional Licenses/ Certifications/ Registrations, and Employment Record sections of the application.
Resumes are NOT used to determine your score/rank. 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 or may lead to a lower score. Verification of education, experience, licensure, and possession of valid certifications/registrations may be collected at any time.
If you experience technical difficulties, make note of any error messages and contact the Analyst prior to the submission deadline.
Responses should be consistent with the information on your employment application and are subject to verification.
PART ONE: EDUCATION, LICENSES AND CERTIFICATION QUALIFICATIONS
INSTRUCTIONS FOR QUESTIONS #1 - #7: Please answer all applicable questions by choosing the best response that matches your education, licenses, registrations and certifications.
1a.
Do you possess a valid permanent/temporary (including interim permit) California Registered Nurse License issued by the California Board of Registered Nursing?
Yes
No
1b.
If you answered “Yes” to question 1a., 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 1a., please provide an explanation below.
2a.
Do you possess a valid permanent/temporary (including interim permit) California Nurse Practitioner (NP) License issued by the California Board of Registered Nursing?
Yes
No
2b.
If you answered “Yes” to question 2a., please provide your California Nurse Practitioner License number, your name as it appears on your Nurse Practitioner License, and the expiration date of your License. If you answered “No” to question 2a., please provide an explanation below.
3a.
Do you have possession of a valid Nurse Practitioner Furnishing License issued by the California Board of Registered Nursing?
Yes
No
3b.
If you answered “Yes” to question 3a., please provide your California Nurse Practitioner Furnishing License number, your name as it appears on your California Nurse Practitioner Furnishing License, and the expiration date of your License. If you answered “No” to question 3a., please provide an explanation below.
4a.
Which of the following degrees do you possess?
Associate's degree in Nursing (ASN/ADN)
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN)
PhD. or DNP in Nursing
None of the above
4b.
Please provide the name of the school and the major course of study for each of the degrees selected in question 4a.
5a.
Do you have possession of a National Board Certification, or eligibility, as a Nurse Practitioner issued by one of the following recognized National Certifying Bodies or Organizations?
American Academy of Nurse Practitioners (AANP)
American Nurses Association – American Nurses Credentialing Center (ANCC)
Pediatric Nursing Certification Board
National Certification Corporation (NCC) for the Women’s Health Care and Neonatal Nursing Specialties
American Association of Critical Care Nurses
Yes
No
5b.
If you answered "Yes" to question 5a., please type the name of the Certificate granting Organization, the Certificate type, the Certificate number, and the expiration date if applicable. If you answered "No" to question 5a., please provide an explanation below.
6a.
What Nurse Practitioner Specialization License or Certification do you possess?
Family Nurse Practitioner (FNP)
Adult Nurse Practitioner (ANP)
Acute Care Nurse Practitioner (ACNP)
Adult Gerontology Nurse Practitioner (AGNP)
Women's Health (WHNP)
Pediatric Nurse Practitioner (PNP)
Psychiatric Nurse Practitioner (PMHNP)
Emergency Nurse Practitioner (FNP)
Other
None
6b.
If you selected "Other" in question 6a., please specify below.
7a.
Do you have possession of a Drug Enforcement Agency (DEA) number to furnish controlled substances?
Yes
No
7b.
If you answered “Yes” to question 7a., please provide your Drug Enforcement Agency (DEA) number to furnish controlled substances. If you answered “No” to question 7a., please type N/A.
8a.
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
8b.
Please provide your name, Certificate number, and the expiration date for each of the American Heart Association CPR Certificates you selected in Question 8a. If you answered "None of the above" to question 8a., please provide an explanation.
9a.
Which of the following electronic medical records software systems do you have experience using?
Invision/LCR
ECW
JIM
EPIC
Cerner
EMAR
ISCHTR
Pulse Check
Salar
Avatar
Oaxaca
Other
None
9b.
If you selected "Other" in question 9a., please specify below.
10a.
Which of the following settings have you worked as a Nurse Practitioner?
If you selected "Other" in question 10a., please specify below.
10c.
Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) for each setting you selected in question 10a.
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 "None," please type N/A.
Do not type “See Resume.”
11a.
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 - 11 months
12 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 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 "No Experience," please type N/A.
Do not type “See Resume.”
12a.
How much verifiable full-time professional Nurse Practitioner work experience do have administering assessments and diagnostic tests, taking History of Present Illness, diagnosing conditions, interpreting labs, and consulting with medical specialties in an Emergency Department of an Acute Care Hospital? (Full-time experience is equivalent to 40 hours per week.)
No Experience
Some, but less than 6 months
6 - 11 months
12 - 23 months
24 or more months
12b.
Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable full-time equivalent professional work experience as indicated in question 12a.
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.”
12c.
Referring to your answers in questions 12a. and 12b., please provide a brief description of your verifiable professional work experience as indicated in questions 12a. and 12b. 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.”
13a.
How much verifiable full-time professional work experience do you have working as a Registered Nurse or Nurse Practitioner in one or more Level I or Level II Trauma Centers (that have been so designated and verified by the American College of Surgeons)? (Full-time experience is equivalent to 40 hours per week.)
No Experience
Some, but less than 12 months
12 to 23 months
24 to 35 months
36 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 full-time equivalent professional 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 "No 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 professional 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 selected "No Experience," please type N/A.
Do not type “See Resume.”
14a.
To which of the following organizations are you an active member and have taken continuing education credits?
American Association of Nurse Practitioners (AANP)
American Association of Critical-Care Nurses (AACN)
Gerontological Advanced Practice Nurses Association (GAPNA)
National Association of Pediatric Nurse Practitioners (NAPNAP)
Other
None
14b.
If you selected "Other" in question 14a., please specify below.
14c.
Please list the continuing education courses attended. If you answered "None" in question 14a., please type N/A.
CERTIFICATION: I certify that I am the author of this form and that all the information presented is true and based upon my experience. I understand that prior to an appointment I may be required to provide written verification of any of the information provided above and that I may be required by the hiring department to participate in performance test(s) during the probationary period. I further understand that any false, incomplete, or incorrect statement may result in disqualification, dismissal, or termination of employment with the City and County of San Francisco.
Department of Human Resources