Fill - Free fillable Mission College Form CDPH 283C CNA HHA renewal application PDF form

CERTIFIED NURSE ASSISTANT (CNA)

AND/OR HOME HEALTH AIDE (HHA)

RENEWAL APPLICATION

(See instructions on the reverse)

State of California- Health and Human Services Agency 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

CNA Renewal (complete sections I, II, III, V, and VII) Certificate number:_________________________

HHA Renewal (complete sections I, II, III, IV, and VII) Certificate number:_________________________

CNA Reactivation (complete sections I, II, III, V, VI, and VII) Certificate number:_________________________

SECTION II (REQUIRED)

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)

___ ___ ___ - ___ ___ - ___ ___ ___ ___

*If you use an invalid SSN, your application process may be delayed

Driver’s License or State ID Number

Number: _____________ State: ___________

Telephone Number

SECTION III (REQUIRED)

1) Subsequent to your last renewal, have you been CONVICTED, at any time, of any crime, other than a minor

Yes

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) Subsequent to your last renewal, has any health-related licensing, certification or disciplinary authority taken Yes No

adverse action (revoked, annulled, cancelled, suspended, etc.) against you?

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

SECTION IV (IF APPLICABLE)

HHA APPLICANTS ONLY:

3) I have successfully completed and included documentation of twenty-four (24) hours of In-Service Training/ Yes No

Continuing Education Units (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 (HHAs may not complete

online CEUs).

SECTION V (IF APPLICABLE)

CNA APPLICANTS ONLY: If you answered “No” to either question number 4 or 5, please go to question 6.

4) I have successfully completed and included documentation of forty-eight (48) hours of In-Service Training/ Yes No

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).

5) Have you worked as a CNA in a facility for compensation (under the supervision of a licensed health professional) Yes No

within your 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.

Facility Name

Telephone Number

Employment Dates

From:

To:

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

Yes No

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.

SECTION VII (REQUIRED)

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 (03/15) This form is available on our website at: www.cdph.ca.gov Page 1 of 2

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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 criminal 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 completion of the CNA renewal requirements, as indicated above on Section A: CNA 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 (Skilled Nursing Facility 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

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 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 (03/15) This form is available on our website at: www.cdph.ca.gov Page 2 of 2

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