State of California- Health and Human Services Agency
CERTIFIED NURSE ASSISTANT (CNA)
INITIAL APPLICATION
(See instructions on the reverse)
MAIL OR FAX APPLICATION TO:
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
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
Check here if you are enrolling in a CNA training program (complete sections I, II, III, IV, and V)
Check here if you have EQUIVALENT TRAINING (complete sections I, II, III, and V)
Check here if you are requesting RECIPROCITY FROM ANOTHER STATE (complete sections I, II, III, and V) Indicate Transferring State:
SE
CTION II (REQUIRED)
Last Name
First Name
MI
Sex
Male
Female
Public Address (Required) - Subject to Public Records Act request release *
City
State
Zip Code
Date of Birth
Social Security Number** (SSN) or Individual Taxpayer Identification Number (ITIN)
Driver’s License or State ID Number
Number: ________________ State: _________
*Pursuant to a court order, the California Department of Public Health will be required 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. (Government Code starting at section 6250.) Court Order: Service Employees 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.
SECTION III (REQUIRED)
Yes
No
1)
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).
- If yes, list conviction:________________________ Court of conviction:______________________ Date:_____________
2)
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:__________________________________
No
Name of school or facility where you received / will receive the CNA training
Telephone Number
Mailing Address (Number and Street or P.O. Box Number)
City State
Zip Code
California Training Program ID Number for CNA (Required)
CNA:_________________
Beginning Date of CNA Training
End Date of CNA Training
________________________________________
____________________________________________________________
Date
SECTION VI: TO BE COMPLETED BY THE REGISTERED NURSE 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 (08/19)
This form is available on our website at: www.cdph.ca.gov
Email inquiries only: cna@cdph.ca.gov
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SECTION IV (IF APPLICABLE)
Confidential Address (For CDPH use only, If left blank all departmental mail will be sent to address above)
City
State
Zip Code
Phone Number***
Check if this is a
cell phone
Email Address***
Yes
Signature
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.
SECTION V (REQUIRED)
click to sign
signature
click to edit
click to sign
signature
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CERTIFIED NURSE ASSISTANT (CNA)
INITIAL APPLICATION INFORMATION
CRIMINAL RECORD CLEARANCE
Upon enrollment in a CDPH-approved training program, the applicant must be fingerprinted through the Live Scan process.
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 (complete sections I, II, III, IV, and V)
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.
B)
EQUIVALENCY-TRAINED NURSE ASSISTANT APPLICANTS (complete sections I, II, III, and V)
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)
This completed Initial Application (CDPH 283 B). If approved, the applicant will be sent information regarding the Competency Evaluation.
b)
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. If
seeking certification with the use of a foreign transcript, a copy of the foreign transcript may be acceptable; and
c)
Proof of work
(paystub or
W2)
s
howing the applicant has provided
nursing
or nursing-related
services
in a facility
t
o 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
d)
A copy of the completed Request for Live Scan Services (BCIA 8016) form.
C)
RECIPROCITY APPLICANTS (complete sections I, II, III, and V)
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)
This completed Initial Application (CDPH 283 B).
b)
A copy of the state-issued certificate; and
c)
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 t
wo (2) years (not required for those who received their initial certification from another state within the last two (2) years); and
d)
A c
opy 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
e)
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
.
D)
CNA RENEWAL INFORMATION
1)
The initial CNA
certificate is issued for two birthdays, not two calendar years, and will expire on your birthday. Each year of the certification period will be
from one birthday to the following birthday. Any additional time from the effective date until the first birthday will be counted towards the first year of the
certification period. 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 health facility to residents for compensation (under the supervision of a
licensed health professional) within your most recent certification period; and
c)
You have successfully obtain
ed
and submitted documentation of forty-eight
(
48)
hours of
In
-Service
Traini
ng (provided by t
he Skilled
Nursing
Facility-SNF employer or Home Health Agency HHA employer or Continuing Education Units (CEUs
) (provided by a non-SNF/HHA 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. CEU certificates must be submitted with the renewal application. 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 CEU computer training programs and CDPH-approved classroom CEU providers.
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 CNA 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.
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.
forementioned requirements are base
A d 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 (08/19)
This form is available on our website at: www.cdph.ca.gov
Email inquiries only: cna@cdph.ca.gov
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