Official SealHuman Resource Services Department


#18-5315-01
Supplemental Questionnaire

Last Name
First Name
 

Applicants for this position are required to submit responses to the following supplemental questions.  Your completed responses to the supplemental questionnaire will be evaluated to determine your qualifications and must be completed properly in order to be given full consideration for the next phase in the selection process. Additionally, your responses will also be evaluated and used in the selection process in order to identify the best qualified applicants.

Responses should be thorough and specific.  A lack of detail and explanation in the supplemental questions and in your application may result in failure or disqualification for this position.  Clarity of expression, content, experience, grammar, spelling and the ability to follow instructions will be considered in the evaluation process.  A resume will not be accepted as a substitute for properly completed responses.

Information provided in your responses to the supplemental questionnaire regarding your employment experiences must also be detailed in the Work Experience section of the application for this recruitment.  Please be sure to list all employers and required information, on your application, especially if you are referencing those employers in your responses to the supplemental questions.

By selecting yes below, you certify your understanding that all applicants must submit a complete application and complete responses to the supplemental questions in order to be considered for this recruitment. Do you understand the above statement?

Yes No
1.

Do you possess a license as a Registered Nurse issued by the California Board of Registered Nursing?

Yes No
 

If yes, please indicate you license number, issuance and expiration dates in the space provided below, otherwise please type "N/A".

2.

Do you possess a California Public Health Nursing (PHN) Certificate?

Yes No
 

If yes, please indicate you certificate number in the space provided below, otherwise please type "N/A".

3.

Registered Nurse IIIs are responsible for leading Registered Nurses and multi-disciplinary staff of an assigned team and/or unit. Please describe your professional experience leading a team to complete a project or investigation. In your response, include your role, the role of the staff you led, and your processes for the following:

a. Defining the project/investigation goals
b. Agreeing upon anticipated outcomes
c. Assigning roles
d. Assuring the quality and timeliness of work
e. Assuring communication among team members and stakeholders

4.

Related to your response to question # 3, what worked well and what would you do differently next time?

5.

Please describe your experience as a registered nurse, providing nursing case management services, information, and referral services to either low-income, high-risk individuals and their families, or individuals affected by communicable disease(s).

6.

Describe a situation where you witnessed a peer practicing outside accepted protocols and procedures. What did you do to address the situation?

7.

Describe your experience working in or with diverse, multi-ethnic, multi-cultural, communities. What have you done to establish and maintain your rapport and working relationships with these communities?

8.

In compliance with the Administrative Simplification provision of the Health Insurance and Accountability Act of 1996 (HIPAA), employees in this classification are required to possess a National Provider Identifier (NPI) number prior to their first day on the job.  Do you understand this statement and are you able to meet this requirement?

Yes No
9.

In compliance with Medicare regulations, eligible licensed clinicians in this classification are required to complete the "Medicare Enrollment Process for Physicians and Non-Physician Practitioners" through the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services, prior to their first day on the job. Active enrollment in Medicare is a condition of employment. Failure to attain or maintain active enrollment will result in termination. 

Do you understand that if you are identified as an eligible licensed clinician you will be required to meet this standard?

Yes No
 

The supplemental questions above were designed to elicit your experience as it relates to the current recruitment in order to identify the best qualified candidates for the position.  Only the most suitably and best qualified candidates will be invited to participate in the oral interviews.  By selecting yes below, you certify your understanding that all applicants who meet the minimum qualifications are not guaranteed to move forward in the process.   Do you understand the above statement?

Yes No
 

The supplemental questions were designed to elicit your experience as it relates to the current recruitment in order to identify the best qualified candidates for this position. Only the best and most suitably qualified candidates will be invited to participate in the oral interviews.

By selecting yes below, you certify your understanding that all applicants who meet minimum qualifications are not guaranteed to move forward in the process. Do you understand the above statement?

Yes No