Fillable NURSE ASSISTANT AND/OR HOME HEALTH AIDE INITIAL APPLICATION (California Baptist University)

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NURSE ASSISTANT AND/OR HOME HEALTH AIDE INITIAL APPLICATION (California Baptist University)

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State of California-Health and Human Services Agency
California Department of Public Health
Licensing and Certification Program (L&C)
Aide and Technician Certification Section (ATCS)
1615 Capitol Avenue, MS 3301
P.O. Box 997416
Sacramento, CA 95899-7416
(916) 327-2445 FAX (916) 552-8785
NURSE ASSISTANT AND/OR HOME HEALTH AIDE
INITIAL APPLICATION
HS 283 B (9/08) This form is available on our website at: www.cdph.ca.gov
Last name
Mailing address (number and street name or P.O. Box number)
Signature of applicant
I certify, under penalty of perjury under the laws of the State of California, that the foregoing is true and correct.
City State ZIP code
Date
Male
Female
(See instructions on the reverse)
First name MI Sex
Date of birth
Place of birth Height Eye color
*Social Security Number (SSN)
Driver's license number
Number:
State:
Telephone number
Weight Hair color
( )
* If you use an invalid Social Security Number, your application will be rejected. (Any SSN beginning with "8" or "9" is invalid.)
1.
Have you been CONVICTED, at any time, of any crime, other than a minor traffic violation?
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 Yes
No Yes
TYPE OF REQUEST (See A or B on the reverse.)
- -
CNA HHA
Check here if you are enrolling in a training program, and complete the school portion below:
Name of school or facility where you received / will receive your nurse assistant or home health aide training.
Mailing address (number and street name or P.O. Box number)
California training program ID number(s)
City
Telephone number
State ZIP code
( )
Nurse Assistant: Home Health Aide:
Beginning date(s) 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.)
Processing Fees Returned: $
TO BE COMPLETED BY THE RN RESPONSIBLE FOR TRAINING OR ATCS
REPRESENTATIVE SPONSORING THE APPLICANT FOR THE NURSE ASSISTANT
COMPETENCY EXAM:
I certify that this individual has successfully completed state and federal nurse
assistant training requirements.
The Applicant's fingerprints were submitted to ATCS upon enrollment and prior to
direct patient contact but clearance is pending for criminal convictions. The nurse
assistant student is eligible to take the competency evaluation (i.e testing).
Signature Date
FOR CDPH USE ONLY
Print Form
OSP 06 96236
INSTRUCTIONS
If you have never been fingerprinted and cleared through ATCS for CNA, HHA certification or ICF-DD, DDH, or DDN employment, fingerprinting is REQUIRED. Effective July 1,
2005, the California Department of Justice (DOJ) will only accept fingerprints done through the Live Scan method. Once the fingerprints are taken through this method, the
fingerprints are transmitted to DOJ electronically. If cleared, DOJ electronically forwards this information to California Department of Public Health (CDPH) within a few days.
Fingerprint Requirements
HS 283 B (9/08) This form is available on our website at: www.cdph.ca.gov
Follow the SAMPLE (modified by ATCS for CNA / HHA certification purposes) for completion of DOJ's NCR form Request for Live Scan Services (BCII 8016) before going to the
Live Scan service site. Check with your training program or local law enforcement agency for location of a Live Scan site. List of sites can be obtained on the Attorney
General's web site at http://ag.ca.gov/fingerprints/publications/contact.htm.
Call the service site chosen to make an appointment. All convictions are reviewed. If the conviction prevents certification, the applicant and employer (if known) will
be notified. Applicants will not receive a certificate until they have been cleared through a background investigation.
A. STUDENTS ENROLLING IN A CNA TRAINING PROGRAM
Upon enrollment in an ATCS-approved 150-hour training program, the applicant must be fingerprinted through the Live Scan method. The applicant or training
program should submit the following to ATCS upon enrollment and before patient contact:
•The completed application form; and
•The second copy of completed BCII 8016 form.
Provided the above has been submitted to ATCS by the applicant or training program, the nurse assistant may work with proof of successful completion of the
competency exam while the background investigation is in progress.
B. HOME HEALTH AIDE (HHA) APPLICANTS
There is no reciprocity granted for HHAs. Applicants must take HHA training from either of the following ATCS-approved training programs:
• 120 hours consisting of at least 65 hours of classroom and 55 hours of supervised clinical training in basic nursing and home health topics.
• 40 hours supplemental HHA training consisting of 20 hours classroom and 20 hours supervised clinical training in home health topics. (This course is
only for individuals who are already CNAs or enrolling in combined [dual] CNA / HHA training programs.)
Upon enrollment in the 120-hour and 40-hour HHA training program, the training program must submit the following to ATCS:
• The second copy of the BCII 8016 form (not required for 40-hour program because fingerprints would have previously been sent); and
• This completed application form.
The applicant may NOT work as a certified HHA until she / he is cleared through a background investigation and receives an HHA certificate.
C. EQUIVALENCY-TRAINED NURSE ASSISTANT APPLICANTS
If the applicant is presently in (or completed) an RN, LVN, or licensed psychiatric technician program (but has not received a CA license); has military services medical
training; or has received the above license(s) from a foreign country or U.S. state, the applicant will not have to take further training and may qualify to take the
competency exam. Submit the following to ATCS:
• An original transcript of training (students can substitute the transcript with a letter on official school letterhead listing equivalent training in at least
"fundamentals of nursing"). If discharged from the military, a copy of the DD-214 can substitute for the original transcript; and
• Proof of work providing nursing services, for compensation in the last two years (not required for nursing students or if the college degree was
received in the last two years); and
• A copy of the completed BCII 8016 form; and
• This completed application form.
If eligible, ATCS will send information regarding taking the exam.
Provided the above has been submitted to ATCS by the applicant or training program, the nurse assistant may work with proof of successful completion
of the competency exam while the background investigation is in progress.
D. CNA RECIPROCITY APPLICANTS FROM OTHER STATES
If the CNA certification is active and in good standing on another state's registry, she / he will qualify for certification in California without taking the CNA training or
competency exam. Submit the following to ATCS:
• A copy of your state-issued certificate; and
• A completed verification form CDPH 931 (to be completed by applicant and the endorsing state agency); and
• Proof of work providing nursing services in the last two years (not required for those who received their initial certificates from another state in the last two years; and
• This completed application form; and
• A copy of the completed Request for Live Scan form (BCII 8016). You must wait until you move to California to obtain fingerprints through this method.
Send in the other items described above in order to get your name into our computer system.
NAME AND ADDRESS CHANGES The CNA / HHA is responsible for notifying ATCS, within 60 days, whenever changes of her / his name, address, or telephone number occur. If
she / he has had a name change, submit legal verification of the change. Indicate the certificate number or SSN for identification purposes.
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 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.
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NURSE ASSISTANT ANDOR HOME HEALTH AIDE INITIAL APPLICATION (California Baptist University)

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Completed 16 August 2020

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