Fillable Cdph283c Certified Nurse Assistant and or Home Health Aide Renewal Application

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Cdph283c Certified Nurse Assistant and or Home Health Aide Renewal Application

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State of California- Health and Human Services Agency
CERTIFIED NURSE ASSISTANT (CNA)
AND/OR HOME HEALTH AIDE (HHA)
RENEWAL APPLICATION
(See instructions on t
he reverse)
MAIL OR FAX APPLICATION TO:
California Department of Public Health (CDPH)
Lic
ensing and Certification Program (L&C)
Aide
a
nd Technic
ian
C
ertificatio
n
Section (ATCS)
MS
3301,
P
.O.
B
ox
997416
Sacramento, CA 95899-7416
PHONE: (916) 327-2445 FAX: (916) 552-8785
THERE IS NO FEE TO PROCESS THIS APPLICATION. YOUR APPLICATION WILL NOT BE PROCESSED IF ALL APPLICABLE QUESTIONS ARE NOT ANSWERED.
SECTION I (REQUIRED)
TYPE OF REQUEST
HHA Renewal (complete sections I, II, III, IV, V (if applicable) and VII)
CNA Renewal (complete sections I, II, III, IV, V and VII)
CNA Reactivation (complete sections I, II, III, IV, V, VI and VII)
Certificate number:_________________________
Certificate number:_________________________
Certificate number:_________________________
SECTION II (REQUIRED)
Las
t Name
First Name MI
Date of Birth
Public Address (Required) - Subject to Public Records Act request release *
City
State
Zip Code
Confidential Address (For CDPH use only, If left blank all departmental mail will be sent to address above)
City
S
tate
Zi
p
Code
Social Security Number** (SSN) or Individual Taxpayer Identification Number (ITIN)
Email Address***
Phone Number***
Check if this is a cell phone
*Effective May 22, 2018, the California Department of Public Health will be required under a court order to release the address of record for certified nurse assistants, home health aides, certified hemodialysis technicians, and licensed nursing home
administrators in response to a Public Records Act (PRA) request. Court Order: Service Employee International Union-United Healthcare Workers v. California Department of Public Health, Sacramento County Superior Court, February 21, 2018, No.
34-2017-80002636. **If you use an invalid SSN, your application process may be delayed ***Providing your telephone number and email address is for the California Department of Public Health's internal use only for contacting applicants. This information
will not be released to the public nor will it be displayed online
No
SECTION III
(REQUIRED)
1)
Since your last renewal, have you been CONVICTED, at any time, of any crime, other than a minor traffic violation?
(You need not 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).
Yes
Yes
No
-If yes, list conviction:________________________ Court of conviction:_________________________ Date:_______________
2)
No
SECTION IV (REQUIRED) - IF APPLYING FOR DUAL CERTIFICATION YOU MUST COMPLETE QUESTIONS 3 AND 4
HHA APPLICANTS ONLY:
3)
I have successfully completed and included documentation of twenty-four (24) hours of In-Service Training/Continuing Education
Units (CEUs) during my most recent certification period. If using In-Service Training you must complete Section V. Twelve (12) of
the twenty-four (24) hours were completed in
each year of my two (2) year certification period (HHAs may not complete online
CEUs).
Yes
No
4)
I have successfully completed and included documentation of forty-eight (48) hours of In-Service Training/CEUs during my most
recent certification period. Twelve (12) of the forty-eight (48) hours were completed in each year of my two (2) year
certification period (CNAs may complete a maximum of twenty-four (24) online CEUs).
Yes
Yes
Yes
No
SECTION V (REQUIRED FOR CNA; IF APPLICABLE FOR HHA IN-SERVICE TRAINING HOURS VERIFICATION)
5)
Have you worked as a CNA/HHA in a facility for compensation (under the supervision of a licensed health professional) within your
most recent two (2) year certification period? If you have, check the “Yes” box and provide the facility information below, as well as
list the dates of employment. If you have not, check the “No” box and you may continue to Section VI (CNA applicants only)
No
Facility Name
Telephone Number
From:(mm/dd/yy)
To:(mm/dd/yy)
Employment Dates
Currently
Working
Mailing Address (Number and Street or P.O. Box Number)
City
State
Zip Code
SECTION VI (IF APPLICABLE)
CNA APPLICANTS WHO DID NOT MEET RENEWAL REQUIREMENTS ONLY:
6)
REACTIVATION: I have not completed one (1) or both of the renewal requirements listed above in questions 4 and 5 and
wish to reactivate my CNA certificate by taking the Competency Evaluation (see C on the reverse). If approved, a
Competency Evaluation approval letter will be sent to you, along with information to schedule
the evaluation.
No
SECTION VII (REQUIRED)
I certify under penalty and perjury under the state and federal laws that the information contained in this application and supporting documents, is true and correct. It shall be unlawful
for any person not certified under Health and Safety Code (1200 - 1797.8) to hold himself or herself out to be a certified nurse assistant and/or home health aide.
______________________________________________
Signature of Applicant
_______________________________________
Date
CDPH 283 C (02/19)
This form is available on our website at: www.cdph.ca.gov
Email inquiries only: cna@cdph.ca.gov
Page 1 of 2
CNA APPLICANTS ONLY:
Since your last renewal, has any health-related licensing, certification or disciplinary authority taken adverse action
(revoked, annulled, cancelled, suspended, etc.) against you?
-If yes, indicate the type and number of license/certificate: __________________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
click to sign
signature
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CERTIFIED NURSE ASSISTANT (CNA)
AND/OR HOME HEALTH AIDE (HHA)
RENEWAL INFORMATION
A) CNA RENEWALS (complete sections I, II, III, V, and VII)
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
of your certificate, if by the time your 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
b)
You have provided nursing or nursing-related services in a health care 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 (provided by the
Skilled Nursing Facility-SNF or Home Health Agency employer) or Continuing Education Units (CEUs) (provided by a non-SNF
employer) within your most recent certification period. The SNF in-service documentation must be submitted on the
CDPH 283A form, including the signature of the instructor responsible for the training. Only CDPH-approved CEU Providers
with a Nurse Assistant Certification Number (NAC#) may provide CEUs for CNAs.
d)
Online CEU certificates must be submitted with the renewal application. 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.
B)
HHA RENEWALS (complete sections I, II, III, IV, and VII)
1) HHA certificates may be renewed any time within four (4) years after the expiration date of your certificate. If by the time your certificate
expires you will have completed the following:
a)
You have previously received and maintained crimi
nal record clearance for CNA, HHA, Intermediate Care Facility-
Developmentally Disabled (ICF-DD), DD Habilitative, or DD Nursing; and
b)
You have successfully obtained and submitted documentation of twenty-four (24) hours of In-Service Training/CEUs within
your most recent certification period. The documentation must include a signature of the instructor who was responsible for the
training. Twelve (12) of the twenty-four (24) hours must be completed in each year of the two (2) year certification period
(HHAs may not complete online CEUs).
2)
If you do not meet the renewal requirement, you must retrain through a CDPH-approved HHA training program to receive an active HHA
certificate.
3)
If you have an active CNA certificate, you may renew your HHA certificate at the same time. Renewing the CNA and HHA certificates
together requires the c
ompletion of both the CNA and HHA renewal requirements, as indicated above on Section A: CNA RENEWALS and
Section B: HHA RENEWALS
.
C)
CNA REACTIVATION (complete sections I, II, III, V, VI, and VII)
1) If you are unable to meet renewal requirements and your certificate has not been expired for more than two (2) years, you may reactivate the
certificate by taking the Competency Evaluation. To apply for reactivation, please submit this completed Renewal Application (CDPH 283 C),
making sure to check the “yes” box for question number six (6) in section VI. If approved, a Competency Evaluation approval letter will be
sent to you, along with information needed to schedule the evaluation. You must successfully pass the evaluation within two (2) years from
your certificate’s expiration date. Once you have successfully passed the evaluation, maintained criminal record clearance, and the results
from the testing vendor have been received, CDPH will issue a current CNA certificate.
D) IN-SERVICE TRAINING/CEUS
1)
All CDPH-approved In-Service Training (SNF, Hosipce, ICF, and Home Health Agency employers) classes are accepted.
2)
Continuing education classes must be taken with CDPH-approved providers only. CDPH-approved CEU providers have a NAC# noted
on the CEU certificate. Approved courses are designed to enhance the knowledge and skills of the CNA/HHA and enhance the skills in the
employer-based healthcare settings.
3)
Licensed Vocational Nurse / Registered Nurse / Licensed Psychiatric Technician Programs: CNA certificate holders will be given credit for
partcipation in
these programs by listing the courses taken and converting the units to hours as follows: semester unit = 15 hours,
quarter unit = 10 hours. You must submit a copy of your school transcript to verify your enrollment and completion of training.
4) HHA Tr
ai
ni
ng P
ro
g
ra
m
(40-hour program): Twenty-six (26) of the forty (40-hour) training program may count towards CEUs.
F)
NAME AND ADDRESS CHANGES
1)
Certificate holders shall notify CDPH within sixty (60) days of any change of address. If requesting 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.
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 C (02/19)
This form is available on our website at; www.cdph.ca.gov
Email inquiries only: cna@cdph.ca.gov
Page 2 of 2
E)
FAILURE TO RENEW PRIOR TO THE EXPIRATION DATE ON THE CERTIFICATE
1)
Certificate holders who fail to renew prior to the expiration date on the certifcate will be placed in a delinquent status. These individuals will
not be verifiable online until the applicant meets all the renewal requirements within the most recent two year certification period. Individuals
in a delinquent status may not hold himself or herself out to be a certified nurse assistant and/or home health aide until the certificate is
renewed and in active status.
2)
Due to the lapse in certifcation the effective date will be changed to the date the application was renewed.
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Completed 12 July 2020

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