Form Cdph 183 – Fill Out and Use This PDF

Form Cdph 183 is a document that contains all the information you need to apply for disability. You can get this form at your local social security office or download it from SSA's site.

The perfect place to edit and work with this form is here. Our hassle-free PDF tool can help you get your form in no time. Pretty much any device you pick, whether it is a PC, laptop, smartphone, or tablet, can be used.

Form Cdph 183 PDF Details

Pursuant to Health and Safety Code section 120310, all health care facilities must complete and submit Form Cdph 183 to the California Department of Public Health. This form is a comprehensive report on the health and safety status of the facility. Completing and submitting this form is a critical step in protecting both patients and staff. The California Department of Public Health reviews Form Cdph 183 submissions on a regular basis to ensure that health care facilities are meeting state safety requirements. Failing to complete and submit this form may result in enforcement action from the department. Healthcare facilities should familiarize themselves with the requirements for completing and submitting Form Cdph 183 prior to submission. For more information, please visit the California Department of Public Health website.

The following are some specifics of form cdph 183. Before you fill out the form, it is usually definitely worth checking out more details on it.

Question	Answer
Form Name	Form Cdph 183
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	lab 183 form, amazon, lab183, cdph lab 183 form

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State of California- Health and Human Services Agency	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
	Date sent: _________________

HOME HEALTH AIDE (HHA) CERTIFICATION LIST

HHA Training Programs must use this form to submit student data to the Aide and Technician Certification

Section (ATCS) for certification UPON COMPLETION of the HHA Training Program.

DO NOT SEND ANY OTHER FORMS WITH THIS FORM.

Name of school or agency presenting program

40-hour program

120-hour program

Date program began

Date program completed

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

City

State

ZIP code

HHA School code

I certify that the students listed below have successfully completed an approved HHA Training Program, and qualify for HHA certification.

Signature of Registered Nurse (RN) responsible for HHA training program					Telephone Number
					(	)

1.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


2.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


3.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


4.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


5.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)

CDPH 183 (04/14)

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

Page 1 of 2

6. Last Name

First Name

Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


7.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


8.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


9.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


10.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


11.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)


12.	Last Name	First Name		MI	Date of birth

Mailing address (number and street name or P.O. Box)			City			State	ZIP Code

*Social Security Number			Telephone Number
_______ _______ _______ - _______ _______ - _______ _______ _______ _______			(	)

(ATTACH ADDITIONAL SHEETS IF NECESSARY)

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 Date 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 examination identification, for identification purposes in national disciplinary databases or as the basis of a

disciplinary action against you.

CDPH 183 (04/14)

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

Page 2 of 2

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