Department of Human Resources

2328 NURSE PRACTITIONER
(ALL SPECIALTIES)
SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine if you meet the minimum qualifications and specialization area requirements, as applicable, of a 2328 Nurse Practitioner, and to evaluate your work experience, licenses and certifications.

Responses to supplemental questionnaire items must be supported by the information provided in the body of your application (i.e., Education, Professional Licenses/Certifications/Registrations, Employment Record sections) in order to receive appropriate credit, and are subject to verification. Verification of education, 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?

As a reminder, all licenses, certifications and registrations must be listed in the application in order to be considered in review of Minimum Qualifications.  If you do not include the licenses, certifications and registrations you are about to describe in the "Professional Licenses, Certifications or Registrations" section of your application, you will not receive credit for the licenses, certifications and registrations.  If you are copying and old application, please take the time to update the appropriate section before submitting your application.

If you answered “Yes” to question 1a., please provide your California Registered Nurse license number, your name as it appears on your Registered Nurse license, and the expiration date of your license.  If you answered “No” to question 1a., please provide an explanation below.

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, all licenses, certifications and registrations must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the licenses, certifications and registrations you are about to describe in the "Professional Licenses, Certifications or Registrations" section of your application, you will not receive credit for the licenses, certifications and registrations. If you are copying an old application, please take the time to update the appropriate section before submitting your application.

If you answered “Yes” to question 2a., please provide your California Nurse Practitioner license number, your name as it appears on your Nurse Practitioner license, and the expiration date of your license. If you answered “No” to question 2a., please provide an explanation below.

Do you possess a valid Nurse Practitioner Furnishing license issued by the California Board of Registered Nursing?

As a reminder, all licenses, certifications and registrations must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the licenses, certifications and registrations you are about to describe in the "Professional Licenses, Certifications or Registrations" section of your application, you will not receive credit for the licenses, certifications and registrations. If you are copying an old application, please take the time to update the appropriate section before submitting your application.

If you answered “Yes” to question 3a., please provide your California Nurse Practitioner Furnishing license number, your name as it appears on your California Nurse Practitioner Furnishing license, and the expiration date of your license. If you answered “No” to question 3a., please provide an explanation below.

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 "Education" section of your application, you will not receive credit for the education. If you are copying an old application, please take the time to update the appropriate section before submitting your application.

Please provide the name of the school and the major course of study for each of the degrees selected in question 4a.

Do you posses 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, all licenses, certifications and registrations must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the licenses, certifications and registrations you are about to describe in the "Professional Licenses, Certifications or Registrations" section of your application, you will not receive credit for the licenses, certifications and registrations. If you are copying an old application, please take the time to update the appropriate section before submitting your application.

If you answered "Yes" to question 5a., please type the name of the certificate granting organization, the certificate type, the certificate number, and the expiration date if applicable.
If you answered "No" to question 5a., please provide an explanation below.

What Nurse Practitioner Specialization License or Certification do you possess?

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

Do you have possession of a Drug Enforcement Agency (DEA) number to furnish controlled substances?

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.

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 8a.  If you answered "None of the above" to Question 8a., please provide an explanation.

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

If you selected "Other" in question 9a., please specify below.

Which of the following settings have you worked as a Nurse Practitioner?

If you selected "Other" in question 10a., please specify below.

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.”

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 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 that you do not have experience, please type N/A.

Do not type “See Resume.”

For Sexually Transmitted Infection (STI) specialty Nurse Practitioner positions, how much verifiable full-time professional Nurse Practitioner work experience do you have working in a setting that treats HIV, AIDS, and Sexually Transmitted Infections? (Full-time 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 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 that you do not have experience, please type N/A.

Do not type “See Resume.”

Referring to your answers in questions 12a. and 12b., please provide a brief description of your verifiable 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 you do not have experience, please type N/A.

Do not type "See Resume."

For Long Term Care/Geriatric specialty Nurse Practitioner positions, how much verifiable full-time Professional Nurse Practitioner work experience do you have providing care to geriatric or severely disabled patients in a long term care facility such as a nursing home, long term rehabilitation center, or hospice?  (Full-time 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 13a.

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 13a. and 13b., please provide a brief description of your verifiable 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 do not have experience, please type N/A.

Do not type "See Resume."

For Occupational Health specialty Nurse Practitioner positions, how much verifiable full-time Health Care Provider experience do you have working in Occupational Health? (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 14a.

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 14a. and 14b., please provide a brief description of your verifiable work experience as indicated in questions 14a. and 14b.  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 coursework do you have in Occupational Health?

Please provide the name of the school and the coursework/degree completed as selected in question 15a. If you have not completed coursework/degree, please type N/A.

Are you certified as a medical examiner with the National Registry of Certified Medical Examiners?

Please provide your National Registry of Medical Examiners Registry Number. If you answered No to question 16a., Please type "N/A".

For Psychiatric specialty Nurse Practitioner positions, how much verifiable experience do you have as a Registered Nurse or Nurse Practitioner in a psychiatric inpatient unit, psychiatric emergency service clinic, or mental health center?  (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 17a.

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 17a. and 17b., please provide a brief description of your verifiable work experience as indicated in questions 17a. and 17b.  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."