Fill - Free fillable Cdph283b2013 (Mission College) PDF form

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

PHONE: (916) 327-2445 FAX: (916) 552-8785 EMAIL: cna@cdph.ca.gov

CERTIFIED NURSE ASSISTANT (CNA)

AND/OR HOME HEALTH AIDE (HHA)

INITIAL APPLICATION

(See instructions on the reverse)

THERE IS NO FEE TO PROCESS THIS APPLICATION. YOUR APPLICATION WILL NOT BE PROCESSED IF ALL APPLICABLE QUESTIONS ARE NOT ANSWERED.

Last Name

First Name

Sex

Male Female

Mailing Address (Number and Street or P.O. Box Number)

City

State

Zip Code

Date of Birth

*Social Security Number (SSN)

___ ___ ___ - ___ ___ - ___ ___ ___ ___

Driver’s License or State ID Number

Number: _______________________

State: _______________________

Telephone Number

Height

Weight

Hair Color

Eye Color

*If you use an invalid SSN, your application will not be processed.

1) Have you been CONVICTED, at any time, of any crime, other than a minor traffic violation? (You need not Yes No

disclose any marijuana-related offenses specified in the marijuana reform legislation and codified at the

Health and Safety Code, Sections 11361.5 and 11361.7).

- If yes, list conviction:________________________ Court of conviction:______________________ Date:________________

2) Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, Yes No

cancelled, suspended, etc.) against you?

- If yes, indicate the type and number of license/certificate:__________________________________

TYPE OF REQUEST (See A or B on the reverse.)

Check here if you are enrolling in a CNA training program and complete the school portion below.

Check here if you are enrolling in a HHA training program and complete the school portion below.

Name of school or facility where you received / will receive the CNA or HHA training

Telephone Number

Mailing Address (Number and Street or P.O. Box Number)

City

State

Zip Code

California Training Program ID Number(s) (Required)

Nurse Assistant:______________________ Home Health Aide:______________________

Beginning Date of Training

End Date of Training

Check here if you have EQUIVALENT TRAINING. (See C on the reverse.)

Check here if you are requesting RECIPROCITY FROM ANOTHER STATE. State:______________ (See D on the reverse.)

NAME AND ADDRESS CHANGES: Certificate holders shall notify CDPH within sixty (60) days of any change of address. If you have had

a name change, submit legal verification of the change (marriage certificate, divorce decree, or court documents). Failure to report a name

or address change may result in the delay or loss of your certification.

I certify, under penalty of perjury under the laws of the State of California, that the foregoing is true and correct.

____________________________________________________________ ________________________________________

Signature of Applicant Date

TO BE COMPLETED BY THE REGISTERED NURSE (RN) RESPONSIBLE FOR THE GENERAL

SUPERVISION OF THE TRAINING PROGRAM: I certify that this individual has successfully

completed state and federal nurse assistant training requirements and is eligible to take the

Competency Evaluation (this section only applies to students that have recently completed a CNA

Training Program in California).

______________________________________ _______________________

Printed Name Title

______________________________________ _______________________

Signature Date

FOR VENDOR USE ONLY

CDPH 283 B (03/13) This form is available on our website at: www.cdph.ca.gov Page 1 of 2

CERTIFIED NURSE ASSISTANT (CNA)

AND/OR HOME HEALTH AIDE (HHA)

INITIAL APPLICATION INFORMATION

CRIMINAL RECORD CLEARANCE

Upon enrollment in a CDPH-approved training program, the applicant must be fingerprinted through the Live Scan process.

For a list of mandatory convictions (which will result in mandatory denial or revocation of certification), please visit our website at: www.cdph.ca.gov. All convictions are

reviewed. If the conviction prevents certification, the applicant will be notified. Applicants will not receive a certificate until they have received a criminal record clearance.

A) CNA APPLICANTS

1) The applicant must submit the following to ATCS upon enrollment in the program and before patient contact:

a) This completed Initial Application (CDPH 283 B); and

b) The second copy of the completed Request for Live Scan Services (BCIA 8016) form.

2) Provided the above has been submitted to ATCS by the applicant, the nurse assistant may work with proof of successful completion of the Competency

Evaluation while the criminal record review is in progress.

B) HHA APPLICANTS

1) Reciprocity is not granted for HHAs. Applicants must complete HHA training from either of the following CDPH-approved training programs:

a) One-hundred and twenty (120-hours) consisting of at least sixty-five (65-hours) of classroom and fifty-five (55-hours) of supervised clinical training in

basic nursing and home health topics.

b) Forty (40-hours) supplemental HHA training consisting of twenty (20-hours) of classroom and twenty (20-hours) of supervised clinical training in home

health topics (this course is only for individuals who are already hold a CNA certificate).

2) Upon enrollment in the one-hundred and twenty (120-hour) and forty (40-hour) HHA training program, the applicant must submit the following to ATCS:

a) The second copy of the completed Request for Live Scan Services (BCIA 8016) form (not required for 40-hour program, as fingerprints would have

previously been received); and

b) This completed Initial Application (CDPH 283 B).

C) EQUIVALENCY-TRAINED NURSE ASSISTANT APPLICANTS

1) If the applicant is presently enrolled in (or completed) a Registered Nurse, Licensed Vocational Nurse, or Licensed Psychiatric Technician program, or has

received medical training in military services, or has received the above license(s) from a foreign country or U.S. state, the applicant may not have to take

further training and may qualify to take the Competency Evaluation. Please submit the following to ATCS:

a) An official, sealed transcript of training (students may substitute the transcript with a sealed letter on official school letterhead, listing equivalent

training and the completion of at least the "Fundamentals of Nursing" course). The letter must include the completion date(s) of the

training/courses and hours/units completed. If discharged from the military, a copy of the DD-214 can substitute for an official transcript; and

b) Proof of work (paystub or W2) showing the applicant has provided nursing or nursing-related services in a facility to residents for compensation

within the last two (2) years (not required for current nursing students or if the college degree was obtained within the last two (2) years); and

c) A copy of the completed Request for Live Scan Services (BCIA 8016) form; and

d) This completed Initial Application (CDPH 283 B).

 If approved, the applicant will be sent information regarding the Competency Evaluation. Provided the above has been submitted to ATCS

by the applicant, the nurse assistant may work with proof of successful completion of the Competency Evaluation while the criminal record

review is in progress.

D) RECIPROCITY APPLICANTS

1) If the CNA certification is active and in good standing on another state's registry, the applicant may qualify for certification in the State of California without taking

CNA training or the Competency Evaluation. Please submit the following to ATCS:

a) A copy of the state-issued certificate; and

b) Proof of work (paystub or W2) showing the CNA has provided nursing or nursing-related services in a facility to residents for compensation within the

last two (2) years (not required for those who received their initial certification from another state within the last two (2) years); and

c) A copy of the completed Request for Live Scan Services (BCIA 8016) form. The applicant must be fingerprinted in the State of California to obtain

criminal record clearance through this method; and

d) A completed Verification of Current Nurse Assistant Certification (CDPH 931) form, which must be completed by the applicant and submitted by the

endorsing state agency; and

e) This completed Initial Application (CDPH 283 B).

E) CNA RENEWAL INFORMATION

1) CNA certificates must be renewed every two (2) years. You may renew your certificate any time within two (2) years after the expiration date, if by the time

the certificate expires you will have completed the following:

a) You have previously received and maintained criminal record clearance for CNA, HHA, Intermediate Care Facility- Developmentally Disabled

(ICF-DD), DD Habilitative, or DD Nursing and a criminal clearance is granted; and

b) You have provided nursing or nursing-related services in a facility to residents for compensation (under the supervision of a licensed health

professional) within your most recent certification period; and

c) You have successfully obtained and submitted documentation of forty-eight (48) hours of In-Service Training/CEUs within your most recent

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. Please visit www.cdph.ca.gov

for a complete listing of CDPH-approved online computer training programs.

F) HHA RENEWAL INFORMATION

1) HHA certificates must be renewed every two (2) years. You may renew your certificate any time within four (4) years after the expiration date, if by the time the

certificate expires you will have completed the following:

a) You have successfully obtained twenty-four (24) hours of In-Service Training/CEUs within your most recent certification period. A minimum of

twelve (12) of the twenty-four (24) hours shall be completed in each year of the two (2) year certification period.

2) If you have an active CNA certificate, you may renew at the same time as your HHA. Renewing the CNA and HHA certificates together requires the

completion and submission of forty-eight (48) hours of In-Service Training/CEUs.

Aforementioned requirements are based on Health and Safety Code commencing with §1337 through 1338.5, 1725 through 1742 and Code of Federal Regulations Title 42,

Chapter IV, commencing with §483.13 and California Code of Regulations, Title 22, commencing with §71801.

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 B (03/13) This form is available on our website at: www.cdph.ca.gov Page 2 of 2

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