All applicants are required to complete the Supplemental Questionnaire as part of the online application process. The purpose of this Supplemental Questionnaire is to (1) determine if you meet the minimum qualifications of a 2322 Nurse Manager in the Long Term Care/Geriatric specialty, and (2) to determine your knowledge, skills, and abilities in job-related areas that have been identified as critical for satisfactory performance in this specialty.
Responses to supplemental questionnaire items must be supported by the information provided in the body of your application (i.e. Higher Education; Professional Licenses, Certifications, or Registrations; Employment Record) in order to receive appropriate credit, and are subject to verification. If you do not include the information you are about to describe in the body of your application, you will not receive credit for them. Resumes are NOT to be 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 complete application. All responses are final and cannot be altered after submission.
Verification of education, experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the selection process. Falsifying one's education, training, or work experience or attempted deception on the application or evaluation may result in disqualification for this and future job opportunities with the City and County of San Francisco.
If you experience technical difficulties, make note of any error messages and contact the Analyst prior to the filing deadline.
INSTRUCTIONS: Please answer all applicable questions by choosing the best response that matches your education, experience, certifications, licenses, and/or by providing the information requested.
PART ONE: Minimum Qualifications Supplemental Questionnaire
Instructions For Questions 1 - 3:
Please answer all applicable questions by choosing the best response that matches your certification(s), education, experience, and license(s).
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, 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.
Yes
No
2.
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 the appropriate section before submitting your application.
Associate 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.
3.
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 experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the experience 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 the appropriate section before submitting your application.
I have NO verifiable experience.
I have some verifiable experience, but less than 1 year (1,999 hours or less) of verifiable experience.
At least 1 year but less than 2 years (2,000 to 3,999 hours) of verifiable experience.
At least 2 years but less than 3 years (4,000 to 5,999 hours) of verifiable experience.
At least 3 years but less than 4 years (6,000 to 7,999 hours) of verifiable experience.
At least 4 years but less than 5 years (8,000 to 9,999 hours) of verifiable experience.
5 years or more (10,000 hours or more) of verifiable experience.
PART TWO: Training & Experience Evaluation
Instruction for Questions 4 - 10:
Please answer all applicable questions by choosing the best response that matches your certification(s), education, experience, and license(s).
4.
Which of the following valid American Heart Association Cardiopulmonary Resuscitation (CPR) certificates do you possess?
As a reminder, all certifications 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.
Basic Life Support (BLS) for Healthcare Providers.
Advanced Cardiovascular Life Supported (ACLS).
Pediatric Advanced Life Support (PALS).
None of the above.
5A.
Which of the following electronic medical records software systems do you have experience using?
As a reminder, all certificates must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the certificate 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.
Invision/LCR.
ECW.
JIM.
EPIC.
Cerner.
EMAR.
ISCHTR.
Pulse Check.
Salar.
ICCA.
Avatar.
Oaxaca.
Other.
None.
5B.
If you selected "Other" in question 5A, please specify below. If you did not select "Other", please write "N/A".
6.
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.)
As a reminder, all experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the experience 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 the appropriate section before submitting your application.
I have NO verifiable experience.
I have some verifiable experience, but less than 1 year (<1,999 hours) of verifiable experience.
At least 1 year but less than 2 years (2,000 to 3,999 hours) of verifiable experience.
2 years or more (4,000 hours or more) of verifiable experience.
7.
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.)
As a reminder, all experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the experience 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 the appropriate section before submitting your application.
I have NO verifiable experience.
I have some verifiable experience, but less than 1 year (1,999 hours or less) of verifiable experience.
At least 1 year but less than 2 years (2,000 to 3,999 hours) of verifiable experience.
At least 2 years but less than 3 years (4,000 to 5,999 hours) of verifiable experience.
3 years or more (6,000 hours or more) of verifiable experience.
8.
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.)
As a reminder, all experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the experience 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 the appropriate section before submitting your application.
I have NO verifiable experience.
I have some verifiable experience, but less than 1 year (1,999 hours or less) of verifiable experience.
At least 1 year but less than 2 years (2,000 to 3,999 hours) of verifiable experience.
At least 2 years but less than 3 years (4,000 to 5,999 hours) of verifiable experience.
3 years or more (6,000 hours or more) of verifiable experience.
9A.
Which of the following Certificates do you possess?
As a reminder, all certificates must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the certificate 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.
Director of Nursing in LTC Certification Program: (DON-CLTC).
RN in Long Term Care Certification Program: (RN-CLTC).
RN-BC Gerontilogical Nursing issued by (ANCC).
Other.
None of the above.
9B.
If you selected "Other" in question 9A, please specify below. If you did not select "Other", please write "N/A".
10.
Do you speak/write/read any of the following languages?
Arabic.
American Sign Language.
Burmese.
Cambodian.
Cantonese.
Japanese.
Korean.
Laotian.
Mandarin.
Russian.
Spanish.
Tagalog (Philippines).
Vietnamese.
None of the above.
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