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#CBT-2328-902932
Supplemental Questionnaire

Last Name
First Name

 

2328 NURSE PRACTITIONER
SPECIALTY: PEDIATRIC
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 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 or reviewed to determine whether you meet the minimum qualifications or 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. Verification of 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 filing deadline. Responses should be consistent with the information on your employment application and are subject to verification.

PART ONE: MINIMUM QUALIFICATIONS SUPPLEMENTAL QUESTIONNAIRE FOR EDUCATION, LICENSES AND CERTIFICATION QUALIFICATIONS INSTRUCTIONS FOR QUESTIONS 

#1 - #6: Please answer all applicable Page 1 of 10 questions by choosing the best response that matches your education, licenses, registrations and certifications.  


1.

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, 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 "Professional Licenses, Certifications or Registrations" section before submitting your application.

Yes No
2.

Do you possess a valid permanent/temporary (including interim permit) California Nurse Practitioner (NP) License 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 "Professional Licenses, Certifications or Registrations" section before submitting your application.

Yes No
3.

Do you possess a valid Nurse Practitioner Furnishing License 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 "Professional Licenses, Certifications or Registrations" section before submitting your application.

Yes No
4.

Which of the following degrees do you possess? 

As a reminder, please include all education in the "Higher Education" section of your application in order to receive credit for this education. If you are copying an old application, please take the time to update the "Higher Education" section before submitting your application.

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
5.

Do you possess 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

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 "Professional Licenses, Certifications or Registrations" section before submitting your application.

Yes No
6.

What Nurse Practitioner Specialization License or Certification do you possess?

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 "Professional Licenses, Certifications or Registrations" section before submitting your application.

Acute Care Nurse Practitioner (ACNP)
Adult Geogontology Acute Care Nurse Practitioner (AGACNP)
Adult Gerontology Nurse Practitioner (AGNP)
Adult Gerontology Primary Care Nurse Practitioner (AGPCNP)
Adult Nurse Practitioner (ANP)
Emergency Nurse Practitioner (ENP)
Family Nurse Practitioner (FNP)
Pediatric Nurse Practitioner (PNP)
Psychiatric Mental Health Nurse Practitioner (PMHNP)
Women's Health Nurse Practitioner (WHNP)
Other
None

 

PART TWO: TRAINING AND EXPERIENCE EVALUATION

INSTRUCTIONS FOR QUESTIONS #7 - #13

  • 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 experience that relates to the question(s) below, please enter “N/A” as your response.

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 Health Care Provider?

Private Outpatient Office
Pediatric Outpatient Clinic
Adult Surgical Center
Adult Community Clinics
Home Health Agencies
School/College/University Clinic
Hospital Inpatient Service
Family Health Center
Long Term Care Facility
Outpatient Specialty Clinic (i.e. Neurology, Oncology, etc.)
Other
None
10b.

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 1 month
1 - 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 you have providing primary medical care for pediatric and young adult populations aged 12-25? (Full-time experience is equivalent to 40 hours per week)

No experience
1-5 months verifiable experience
6-11 months verifiable experience
12-23 months verifiable experience
24 or more months verifiable experience
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 Nurse Practitioner work experience do have providing Breast and Pelvic Exams, Birth Control including Long-Acting Reversible Contraceptives (LARCs), Incision and Drainage, Suturing, and Splinting?  (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some, but less than 1 month
1 - 11 months
12 or more months
13b.

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 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 you selected "No Experience," please type N/A.

Do not type “See Resume.”

 

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.