Cdph Cna PDF Details

If you are interested in a career as a certified nurse assistant, the California Department of Public Health (CDPH) offers a certification program that will help you prepare for the role. The CNA certification program provides all the information and training you need to work in various healthcare settings, including long-term care facilities, hospitals, clinics, and doctor's offices. In this article, we'll explore what the CDPH CNA certification program entails and how to apply for it.

The listing features information about the cdph cna. You'll have the estimated time you will need to prepare the form and some further details.

QuestionAnswer
Form NameCdph Cna
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescdph cna renewal form, request cdph california, cna renewal form, california form cdph

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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:

SECTION II (REQUIRED)

 

Last Name

First Name

MI

Sex

 

 

 

 

 

 

Male

Female

 

 

Public Address (Required) - Subject to Public Records Act request release *

City

State

Zip Code

 

 

 

 

 

 

 

 

 

Confidential Address (For CDPH use only, If left blank all departmental mail will be sent to address above)

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: _________

Email Address***

Phone Number***

Check if this is a

cell phone

 

*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)

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,

cancelled, suspended, etc.) against you?

Yes

No

 

-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 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

SECTION V (REQUIRED)

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.

____________________________________________________________

________________________________________

Signature

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

Page 1 of 2

 

 

Email inquiries only: cna@cdph.ca.gov

 

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) 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.

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 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.

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 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.

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.

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 (08/19)

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

Page 2 of 2

 

 

Email inquiries only: cna@cdph.ca.gov

 

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ca cdph cna Has any healthrelated licensing, cancelled suspended etc against you, If yes indicate the type and, Yes, SECTION IV IF APPLICABLE, Name of school or facility where, Telephone Number, Mailing Address Number and Street, City, State, Zip Code, California Training Program ID, CNA, Beginning Date of CNA Training, and End Date of CNA Training fields to fill out

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