Department of Human Resources

Part 1: Education & Experience Qualifications

Instructions For Questions #1 - #2: Please answer all applicable questions by choosing the best response that matches your education, experience, certifications, and licenses.

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

As a reminder, all licenses must be listed in the application in order to be considered in review of Minimum Qualifications.  If you do not include the license you are about to describe in the "Professional Licenses, Certifications or Registrations" section of your application, you will not receive credit for this experience.  If you are copying an old application, please take the time to update the appropriate section before submitting your application.

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

As a reminder, all education must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the education you are about to describe in the Education section of your application, you will not receive credit for this experience.  If you are copying an old application, please take the time to update your Education before submitting your application.

How much verifiable full-time equivalent work experience do you have as a Registered Nurse in a long term care facility, rehabilitation, or acute care hospital within the last five (5) years? (Full-time experience is equivalent to 40 hour per week.)

As a reminder, all work experiences must be listed in the application in order to be considered in review of Minimum Qualifications.  If you do not include the license you are about to describe in the Experience section of your application, you will not receive credit for this experience.  If you are copying an old application, please take the time to update your Experience before submitting your application.

PART TWO: TRAINING AND EXPERIENCE EVALUATION

INSTRUCTION FOR QUESTIONS #4 - #9:

• Review the questions first, prepare and save your responses in a word processing document, and then paste them into the online Supplemental Questionnaire.
• Be concise but thorough.  Ensure that you address all parts of the question.  Your written communication skills will be evaluated based on your responses.
• Ensure that your responses are sufficiently detailed to assist in evaluating your knowledge, skills, and abilities.
• Provide your best or highest examples of work.
• Answer all questions independently (e.g., do not reference your responses in prior questions).  Provide all information requested even if they appear redundant.  Do not write "see application" or "see resume" as a response.
• If you do not have the experience that relates to the question(s) below, please enter "N/A" as your response.

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 4. If you answered "None of the above" to question 4, please provide an explanation.

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

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

How much verifiable full-time equivalent 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 verifiable work experience as indicated in question 6.

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 6 and 6a, 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.”

How much verifiable full-time equivalent work experience do you have working at a certified rehabilitation service - either acute or skilled nursing? (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 7.

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 7 and 7a, 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 you do not have experience, please type N/A.

Do not type “See Resume.”

How much verifiable full-time equivalent work experience do you have working with patients who have psychiatric diagnoses? (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 8.

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 8 and 8a, 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.”

Which of the following Certificates do you possess?

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

Please provide your Certificate number, your name as it appears on your Certificate, and the expiration date, if any, for each of the Certificates you selected in question 9. If you selected "None of the above" in Question 9, please type N/A.