Department of Human Resources

2323 CLINICAL NURSE SPECIALIST SPECIALTY: LONG TERM

CARE/GERIATRIC NURSING 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 experience in the education, license/certification/registration, work history and education 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/certificates may be collected at any time.

If you experience technical difficulties, make note of any error messages and contact the analyst before the filing deadline. Responses should be consistent with the information on your employment application and are subject to verification.

PART ONE: EDUCATION AND EXPERIENCE QUALIFICATIONS

INSTRUCTIONS FOR QUESTIONS #1 - #4: 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 your Education before submitting your application.

Do you have possession of a Clinical Nurse Specialist Certificate issued by the California Board of Registered Nurses?

As a reminder, all licenses/certifications must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the license/certification 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 your Education before submitting your application.

Which of the following degrees do you possess? 

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 “Basic Education” and “Higher Education” sections 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 work experience do you have as a Registered Nurse in a skilled nursing facility, long term care or rehabilitation setting within the last five (5) years; OR as a Registered Nurse treating chronic illness and care management in an acute care setting within the last five (5) years? (Full-time is equivalent to 40 hours per week.)

As a reminder, all qualifying experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the work experience you are about to describe in the “Employment Record” 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 Employment Record before submitting your application.

PART TWO: TRAINING AND EXPERIENCE EVALUATION

INSTRUCTIONS FOR QUESTIONS #5 - #10:

• 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 5a.  If you answered "None of the above" to question 5a., please provide an explanation.

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

If you selected "Other" in question 6a., please specify below.

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)

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 7a.

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 7a. and 7b., please provide a brief description of your verifiable professional 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 experience do you have formulating standards of care in management of disease processes? (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 full-time equivalent professional work experience as indicated in question 8a.

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 8a. and 8b., please provide a brief description of your verifiable professional 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.”

How much verifiable full-time work experience do you have initiating or implementing performance improvement projects and evidence based studies? (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 full-time equivalent professional work experience as indicated in question 9a.

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 9a. and 9b., please provide a brief description of your verifiable professional work experience as indicated in questions 9a. and 9b. 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 experience do you have providing on the spot teaching and training to bedside staff and clients? (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 full-time equivalent professional work experience as indicated 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 that you do not have experience, please type N/A.

Do not type “See Resume.”

Referring to your answers in questions 10a. and 10b., please provide a brief description of your verifiable professional work experience as indicated in questions 10a. and 10b. 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.”