Lab183 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.

QuestionAnswer
Form NameForm Cdph 183
Form Length2 pages
Fillable?Yes
Fillable fields216
Avg. time to fill out21 min 53 sec
Other nameslab 183 form, lab183, lab 183, lab 183 12 09

Form Preview Example

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

MI

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

How to Edit Form Cdph 183

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