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Supplemental Questionnaire

Last Name
First Name


P103 Per Diem Registered Nurse

The purpose of this Supplemental Questionnaire is to determine if you meet the Minimum Qualifications of a P103 Per Diem Registered Nurse, and to evaluate your Registered Nurse work experience and certifications.

Responses to supplemental questionnaire items must be supported by the information provided in the body of your application (i.e. education and training/employment/license record section) in order to receive appropriate credit, and are subject to verification. Verification of experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the selection process.

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.


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

Yes No

If you answered "Yes" to Question 1A., please provide your California Registered Nurse license number, your name as it appears on your RN license, and the expiration date of your license. If you answered "No" to Question 1A., please provide additional information below.


Please read the list below, and select the settings, units, or equivalent specialty area where you have obtained work experience as a Registered Nurse.

Medical/Surgical Unit:
Experience working in outpatient specialty or inpatient medical or surgical units. Work experience in these areas does not include Trauma, Emergency Departments, Critical Care Units, or Intensive Care Units.
Trauma Unit:
Work experience in an inpatient unit provides the first line of treatment to trauma related injuries with the goal of stabilizing patients to then be transferred to appropriate units.
Critical Care:
Experience working in an Intensive Care Unit (ICU), Neonatal Intensive Care Unit (NICU), or Critical Care Unit.
Post Anesthesia Care Unit (PACU):
Experience in post anesthesia care.
Emergency Department:
Experience in an Emergency Department or Flight Nurse experience.
Experience in an operating room, including scrubbing and circulating.
Experience working with Pediatric and Neonatal populations in Primary Care, Acute Care, or other outpatient specialty settings.
Experience working in Labor and Delivery and/or Postpartum nursing care.
Maternal Child Adolescent Health (MCAH):
Experience working with new and first time mother to consult and monitor at-risk pregnancies and provide continued post-partum care.
Urgent Care Clinics:
Experience in Urgent Care Clinics that have inpatient capacity.
Ambulatory Clinics/Primary Care:
Experience in Primary Care and Ambulatory clinics for various patient populations and age groups.
Sexually Transmitted Infection (STI)/HIV:
Experience working in clinics or settings focusing on testing, diagnosis, treatment, and management of various Sexually Transmitted Infections including long term management of HIV, consultation, and treatment planning.
Homeless/Indigent Population Care:
Experience providing critical services to homeless/indigent populations, which includes experience treating illnesses specific to these populations and experience collaborating with community based organizations.
Population Health/Public Health Nursing:
Experience with disease surveillance, community testing, community based health programs, immunizations, Tuberculosis, or travel clinic actives.
Psychiatric/Behavioral Health:
Experience working with Psychiatric patients in outpatient and/or inpatient settings.
Correctional Facilities:
Primary, Ambulatory, or Acute care experience in a correctional facility.
Forensic Nursing:
Experience working with victims of crimes that require appropriate considerations to the victim's psycho-social and physical well-being, while collecting evidence for law enforcement activities.
Long-Term Care/Geriatrics:
Experience treating chronic illness, long-term acute rehabilitation experience, and treating populations with neurodegenerative disease.
Acute Rehabilitation/Skilled Nursing Facility:
Short-term rehabilitation or skilled nursing facility experience providing care to post-operative patients recovering from various trauma related injuries, neuro-disruptive events, and severe cardiac, neuro, and other related surgery.
Home Health:
Experience working in a Licensed Home Health Agency.
Occupational Health:
Duties include employee pre-employment diagnostic tests, immunizations, and assistance with fitness for work and return to work physical exams.
Quality Management/Quality Improvement/Utilization Management:
Experience in regulatory compliance, care quality analysis, and utilization management within various healthcare settings and agencies.
Informatics/Electronic Health Records (EHR) Specialist:
Nurse Informatics experience involves data analysis throughout a care delivery system by utilizing electronic health records systems and patient charting systems. Experience may also include assisting with upgrades to Electronic Health Records systems and Patient Charting systems.
Please specify below.
None of the above

If you selected "Other" in question 2A., please specify below.


Please state the employer where you obtained your work experience as indicated in Question 2A. Include your dates of employment and the names of supervisors that can verify your work experience. In addition, please provide a brief description of your specific duties as related to the specific items selected in Question 2A.


Please select the valid Certifications you possess from the list below.

Basic Life Support (BLS)
Advanced Cardiac Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
Neonatal Resuscitation Program (NRP)
Certified Medical-Surgical RN (CMSRN)
Critical Care nurse for adult, pediatric and neonatal pop (CCRN)
Trauma Nurse Core Curriculum (TNCC)
Certified Emergency Nurse (CEN)
Emergency Nursing Pediatric Course (ENPC)
Certified Nurse, Operating Room (CNOR)
International Board Certified Lactation Consultant (IBCLC)
Neonatal Intensive Care Nursing (RNC-NIC)
Certified Asthma Educator (AE-C)
Certified Diabetes Educator (CDE)
Advanced Burn Life Support (ABLS)
Public Health Nurse
Certified Neuroscience RN (CNRN)
Certified Hospice and Palliative Nurse (CHPN)
Certified Rehabilitation RN (CRRN)
Home Health Case Manager Certificate
Home Health Nurse Certificate
Certified Occupational Health Nurse (COHN)
Certified Occupational Health Nurse Specialist (COHN-S)
Obstetric Life Support (OBLS)
Clinical Nurse Leader (CNL)
Certified Associate Health Information Management Systems (CAHIMS)
Certified Professional Health Information Management Systems (CPHIMS)
RN-BC (Please indicate below)
Other (Please indicate below)
None of the above

If you selected "(RN-BC)" or "Other" in question 3A., please specify below.


Please provide your name, Certificate number, and the expiration date for each of the Certificates you selected in Question 3A. If you answered "None of the above" to question 3A., please type N/A.


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.