Fillable CERTIFIED NURSE ASSISTANT (CNA) / HOME HEALTH AIDE

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CERTIFIED NURSE ASSISTANT (CNA) / HOME HEALTH AIDE

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State of California- Health and Human Services Agency California Department of Public Health (CDPH)
Licensing and Certification Program (L&C)
Aide and Technician Certification Section (ATCS)
MS 3301, P.O. Box 997416
Sacramento, CA 95899-7416
(916) 327-2445 FAX (916) 552-8785 cna@cdph.ca.gov
CERTIFIED NURSE ASSISTANT (CNA) / HOME HEALTH AIDE (HHA)
IN-SERVICE TRAINING / CONTINUING EDUCATION UNITS (CEUs)
Printed Name of CNA/HHA
Signature of CNA/HHA
Certificate Number
*Social Security Number
To assure the availability of trained personnel in Skilled Nursing (SNF) and Intermediate Care Facilities (ICF), the Legislature intends that all such facilities in
California participate in approved training programs. All approved In-Service Training programs are specified to enhance the knowledge and skills, assure
continuing competency, and address performance issues one may be experiencing as a CNA/HHA. CNAs are to receive the normal hourly wage for attending
the In-Service on their regularly scheduled shift or during another shift. Only CDPH-approved In-Service Training Programs and CDPH-approved CEU
providers with a Nurse Assistant Certification Number (NAC#) are accepted. CNAs and HHAs that are employed in a SNF, ICF, or Home Health Agency
will submit the information below to ATCS for validation of the renewal requirements. CNAs or HHAs that obtain CEUs from CDPH-approved CEU providers
must attach a copy of each individual CEU course certificate for renewal validation to this form.
A) CNAs: Must obtain forty-eight (48) hours of In-Service Training/CEUs within the certification period. A minimum of twelve (12) of the forty-eight (48)
hours shall be completed in each year of the two (2) year certification period. A maximum of twenty-four (24) of the forty-eight (48) hours may be
obtained only through a CDPH-approved online computer training program listed on our website. Online CEU certificates must be attached to this
form for validation. Please visit www.cdph.ca.gov
for a complete listing of CDPH-approved classroom and online computer CEU providers. If the
HHA Training Program (40-hour program) was completed during the certification period, twenty-six (26) of the forty (40-hour) training program may
count towards CEUs.
B) HHAs: Must obtain twenty-four (24) hours of In-Service Training/CEUs within the certification period. Twelve (12) of the
twenty-four (24) hours are required in each year of the two (2) year certification period
(HHAs may not use online CEUs to meet the requirement).
C) CNA & HHA: Follow section A to renew both certificates.
D) Continuing Education: CEUs must be taken with CDPH-approved providers only with a NAC#. These courses are designed to enhance the
knowledge and skills of the CNA/HHA and enhance the skills in the employer-based healthcare settings.
E) Licensed Vocational Nurse / Registered Nurse / Licensed Psychiatric Technician programs: CNA/HHA certificate holders will receive
In-S
ervice Training/CEUs for completion of these courses by converting the units into hours as follows: one (1) semester unit = fifteen (15) hours,
one (1) quarter unit = ten (10) hours. You must submit a copy of your school transcript to verify your enrollment.
TITLE OF TRAINING OR COURSE
☒ (Check box for Online Training)
SNF/ICF/Home Health Agency Name
and CDPH In-Service ID#
Or CDPH-approved CEU Provider Name and NAC#
DAT
E OF
ATTENDANCE
HO
URS
SIGNATURE OF INSTRUCTOR
RESPONSIBLE FOR TRAINING
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This record shall be submitted with the Renewal Application (CDPH 283 C) and retained by the CNA/HHA for a period of four (4) years.
CDPH 283 A (03/15) This form is available on our website at: www.cdph.ca.gov Page 1 of 2
SNF/ICF/Home Health Agency Name
and CDPH In-Service ID#
Or CDPH-approved CEU Provider Name and NAC#
DATE OF
ATTENDANCE
HOURS
OBTAINED
SIGNATURE OF INSTRUCTOR
RESPONSIBLE FOR TRAINING
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Please copy this page if additional pages are needed.
TOTAL HOURS:
This record shall be submitted with the Renewal Application (CDPH 283 C) and retained by the CNA/HHA for a period of four (4) years.
INFORMATION COLLECTION AND ACCESS-PRIVACY STATEMENT
*Social Security Number Disclosure: Pursuant to Section 666(a)(13) of Title 42 of the United States Code and California Family Code Section 17520, subdivision (d), the California Department of Public Health
(CDPH) is required to collect social security numbers from all applicants for nursing assistant certificates, home health aide certificates, hemodialysis technician certificates or nursing home administrator licenses.
Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support orders upon request by the Department of Child Support Services and for reporting
disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR §§ 61.1 et seq. Failure to provide your social security number will result in the return of your application. Your social
security number will be used by CDPH for internal identification, and may be used to verify information on your application, to verify certification with another state's certification authority, for exam identification,
for identification purposes in national disciplinary databases or as the basis of a disciplinary action against you.
CDPH 283 A (3/15) This form is available on our website at: www.cdph.ca.gov Page 2 of 2
TITLE OF TRAINING OR COURSE
☒ (Check box for Online Training))
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CERTIFIED NURSE ASSISTANT (CNA) HOME HEALTH AIDE

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Completed 9 July 2021

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