Cdph 283B Form – Fill Out and Use This PDF

Last name

First name

MI

Sex

Male

Female

Mailing address (number and street name or P.O. Box number)

City

State

ZIP code

Date of birth

*Social Security Number (SSN)

Driver's license number

Telephone number

-

-

Number:

State:

(

)

Height

Weight

Hair color

Eye color

* If you use an invalid Social Security Number, your application will be rejected.

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:

TYPE OF REQUEST (SEE A OR B ON THE REVERSE.)

Check here if you are enrolling in a Certified Nurse Assitant (CNA) training program, and complete the school portion below.

Check here if you are enrolling in a Home Health Aide (HHA) training program, and complete the school portion below.

Name of school or facility where you received / will receive your CNA or HHA training		Telephone number
		(	)
Mailing address (number and street name or P.O. Box number)	City	State	ZIP code

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.)

NAME AND ADDRESS CHANGES: You are responsible for notifying ATCS, within sixty (60) days, whenever changes in your name, address, or telephone number occur. If you have had a name change, submit legal verification of the change. Indicate the certificate number or SSN for identification purposes. Failure to do so could result in the delay or loss of your certification.

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

Print Name of RN

Signature of RN	Date

CDPH 283B (07/11) This form is available on our website at: www.cdph.ca.gov

INSTRUCTIONS

CRIMINAL RECORD CLEARANCE

Upon enrollment in a CDPH-approved training program, the applicant must be fingerprinted through the Live Scan process.

For a list of mandatory convictions (which will result in mandatory denial or revocation of certification) please visit our website at: www.cdph.ca.gov. 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. CERTIFIED NURSE ASSISTANT (CNA) APPLICANTS

The applicant or training program should submit the following to ATCS upon enrollment and before patient contact:

●This completed application form; AND

●The second copy of the completed Request for Live Scan Services (BCIA 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 evaluation while the criminal record review 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 CDPH-approved training programs:

●120 hours consisting of at least sixty-five (65) hours of classroom and fifty-five (55) hours of supervised clinical training in basic nursing and home health topics.

●Forty (40) hours supplemental HHA training consisting of twenty (20) hours classroom and twenty (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 completed Request for Live Scan Services (BCIA 8016) form (not required for 40-hour program because fingerprints would have previously been sent); AND

●This completed application form.

C. EQUIVALENCY-TRAINED NURSE ASSISTANT APPLICANTS

If the applicant is presently in (or completed) a Registered Nurse, Licensed Vocational Nurse, or Licensed Psychiatric Technician program or has medical training in military services; 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 evaluation. Submit the following to ATCS:

●An official, sealed transcript of training (students can substitute the transcript with a sealed letter on official school letterhead listing equivalent training in at least "fundamentals of nursing". The letter must include the completion date(s) of training). 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 (2) years (not required for nursing students or if the college degree was received in the last two (2) years); AND

●A copy of the completed Request for Live Scan Services (BCIA 8016) form; AND

●This completed application form.

If eligible, ATCS will send information regarding taking the competency evaluation.

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 evaluation while the criminal record review 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, the applicant may qualify for certification in the State of California without taking the CNA training or competency evaluation. Submit the following to ATCS:

●A copy of the state-issued certificate; AND

●Proof of work providing nursing services in the last two (2) years (not required for those who received their initial certificates from another state in the last two (2) years); AND

●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

●A completed Verification of Current Nurse Assistant Certification (CDPH 931) form (to be completed by applicant and submitted by the endorsing state agency); AND

●This completed application form.

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.

CDPH 283B (07/11) This form is available on our website at: www.cdph.ca.gov