Fillable Printable Certified Nurse Assistant and or Home Health Aide Initial Application - California

Certified Nurse Assistant and or Home Health Aide Initial Application - California

CERTIFIED NURSE ASSISTANT (CNA)

AND/OR HOME HEALTH AIDE (HHA)

INITIAL 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

EMAIL: [email protected]a.gov

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 are enrolling in a HHA 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 State:________

SECTION II (REQUIRED)

Last Name First Name MI 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

Height Weight Hair Color Eye Color

SECTION III (REQUIRED)

Have you been CONVICTED, at any time, of any crime, other than a minor traffic violation? (You need

Yes No

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, Yes No

annulled, cancelled, suspended, etc.) against you?

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

SECTION IV (IF APPLICABLE)

Name of school or facility where you received / will receive the CNA or HHA 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) or

California Training Program ID Number for HHA (Required)

CNA:_________________ HHA:_________________

Beginning Date of CNA Training

Beginning Date of HHA Training

End Date of CNA Training

End Date of HHA Training

SECTION V (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

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 (06/15)

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)

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) HHA APPLICANTS (complete sections I, II, III, IV, and V)

1) Upon enrollment in the HHA training program, the applicant must submit the following to ATCS:

a) This completed Initial Application (CDPH 283 B).

b) The second copy of the completed Request for Live Scan Services (BCIA 8016) form (not required for applicants who are in a CNA training

program); and

c) The Home Health Aide Certification List (CDPH 183), which is to be submitted by the training program after successful completion of the program.

C) 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) showing the applicant has provided nursing or nursing-related services in a facility to 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.

D) RECIPROCITY APPLICANTS (complete sections I, II, III, and V)

Reciprocity is not granted for HHAs

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 two (2) years (not required for those who received their initial certification from another state within the last two (2) years); and

d) A copy 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.

E) CNA RENEWAL INFORMATION

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, 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

F) HHA RENEWAL INFORMATION

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 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. A minimum of twelve (12)

of the twenty-four (24) hours shall be completed in each year of the two (2) year certification period (HHAs may not complete online CEUs).

b) If you do not meet the renewal requirement, you must retrain through a CDPH-approved HHA training program to receive an active HHA

certificate.

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.

G) 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 B (06/15)

This form is available on our website at: www.cdph.ca.gov Page 2 of 2

You have successfully obtained and submitted documentation of forty-eight (48) hours of In-Service Training (provided by the 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.