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Cdph283c2013 (Mission College)

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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
PHONE: (916) 327-2445 FAX: (916) 552-8785 EMAIL: cna@cdph.ca.gov
CERTIFIED NURSE ASSISTANT (CNA)
AND/OR HOME HEALTH AIDE (HHA)
RENEWAL 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
MI
Sex
Male Female
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
*If you use an invalid SSN, your application will not be processed.
TYPE OF REQUEST
CNA Renewal HHA Renewal
Certificate number:____________________________________ Certificate number: ____________________________________
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:__________________________________
HHA APPLICANTS ONLY:
3) I have successfully completed twenty-four (24) hours of In-Service Training/Continuing Education Units Yes No
(CEUs) during my most recent certification period. Twelve (12) of the twenty-four (24) hours were completed
in each year of my two (2) year certification period.
Employer Name
Telephone Number
Last Date Worked (please indicate
“currently working” if presently employed)
Mailing Address (Number and Street or P.O. Box Number)
City
State
Zip Code
REACTIVATION:
6) CNA APPLICANTS ONLY: I have not completed one (1) or both of the renewal requirements listed above Yes No
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 examination.
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
CDPH 283 C (08/12) 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)
RENEWAL INFORMATION
A) CNA RENEWALS
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 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.
B) HHA RENEWALS
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
of your certificate, if by the time your 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.
C) CNA REACTIVATION
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 reactivate the CNA certificate, please submit this completed Renewal Application
(CDPH 283 C), making sure to check the “yes” box for question number six (6) in the “Reactivation” section. If approved, a Competency
Evaluation approval letter will be sent to you, along with information needed to schedule the examination. You must complete the
examination within two (2) years from your certificates expiration date. Once you have successfully passed the examination, 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 classes are accepted.
2) Continuing education classes may be taken at CDPH-approved providers, community/state colleges, adult education or regional occupation
programs, general acute care hospitals, American Red Cross or home health agencies, state long-term care ombudsman, or providers
approved by the nursing boards.
a) A partial (but not limited to) list of acceptable continuing education classes are Anatomy, Physiology, Biology, Microbiology,
Psychology, Chemistry, Anthropology, Cultural Anthropology, Sociology, Pharmacology, Medical Terminology, Epidemiology,
Environment Medicine, Communication, Stress Management, Hygiene/Health, Nutrition, Languages, Diseases,
Physiotherapeutic, Message, Therapeutic Physical Training, CPR, Ethics, Child Development, Maternal Health, Pediatrics,
Geriatric courses, Mathematical courses, Sign Language, Environmental Medicine, Holistic Medicine, Phlebotomy, or First Aid.
You must submit a copy of your school transcript to verify your enrollment.
3) Licensed Vocational Nurse / Registered Nurse / Licensed Psychiatric Technician Programs: CNA certificate holders will be given credit for
time 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.
4) HHA Training Program (40-hour program): Twenty six (26) of the forty (40-hour) training program may count towards CEUs.
E) NAME AND ADDRESS CHANGES
1) 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.
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 (08/12) This form is available on our website at: www.cdph.ca.gov Page 2 of 2
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Completed 23 July 2020

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