Department of Human Resources

2328 NURSE PRACTITIONER
SPECIALTY: PSYCHIATRIC SUPPLEMENTAL QUESTIONNAIRE

All applicants are required to complete the Supplemental Questionnaire as part of the online application process. 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.

Responses to items on the Supplemental Questionnaire must be supported by the information provided on your application in order to receive appropriate credit. Please provide all information requested even if the information may appear redundant. Responses cannot be changed or edited after submission. Insufficient or non-responsive answers to the Supplemental Questionnaire may result in ineligibility, disqualification or lead to lower scores.

All licenses/certifications/registrations, education, and experience referenced in this questionnaire MUST also appear in the Professional Licenses/Certifications/Registrations, Education, and/or Employment Record sections of your application. The information provided must be consistent with the information on your application and is subject to verification.

Verification of education, experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the 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. If you experience difficulties, make note of any error messages, and contact the Analyst prior to the filing deadline.

PART ONE: EXPERIENCE, LICENSES AND CERTIFICATION QUALIFICATIONS

INSTRUCTIONS FOR QUESTIONS #1 - #6: Please answer all applicable questions by choosing the best response that matches your work experience, licenses, and certifications.

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 Registered Nurse license, and the expiration date of your license.  If you answered “No” to question 1a., please provide an explanation below.

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

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.

Do you have possession of a valid Nurse Practitioner Furnishing license issued by the California Board of Registered Nursing?

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.

Which of the following degrees do you possess? 

Please provide the name of the school and the major course of study for each of the degrees selected in question 4a.

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

What Nurse Practitioner Specialization License or Certification do you possess?

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

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.

Do you have possession of a Drug Enforcement Agency (DEA) number to furnish controlled substances?

If you answered “Yes” to question 6a., please provide your Drug Enforcement Agency (DEA) number to furnish controlled substances. If you answered “No” to question 6a., please type N/A.

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

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.

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

If you selected "Other" in question 8a., please specify below.

Which of the following settings have you worked as a Nurse Practitioner?

If you selected "Other" in question 9a., please specify below.

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 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 "None," please type N/A.

Do not type “See Resume.”

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.)

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

Do not type “See Resume.”

How much full-time equivalent work experience do you have as a Registered Nurse or Nurse Practitioner in a psychiatric inpatient unit, psychiatric emergency service clinic, or mental health center? (Full-time 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 full-time equivalent professional 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.”

Referring to your answers in questions 11a. and 11b., please provide a brief description of your verifiable professional 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.”

How much verifiable full-time equivalent professional, preceptorship, or volunteer work experience do you have coordinating patient care with community based mental health services including clinics, therapy, and substance abuse programs as part of your care plans? Coordinating Patient Care with a Community Based Organization refers to linking and referring patients to Human Services and Health Service agencies to ensure continued treatment of the patient. (Full-time 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 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 that you do not have experience, please type N/A.

Do not type “See Resume.”

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

Do not type “See Resume.”