Form CDPH 276C – Fill Out and Use This PDF

NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM

INDIVIDUAL STUDENT RECORD

TYPE OR PRINT LEGIBLY

Instructor: Date and initial in the theory column when student completes hours.

				CONTENT
			Prior to any direct contact with a patient, at least a total of sixteen (16) hours of training shall be provided in
			the following areas:
			1)	Communications and interpersonal skills	Modules 1, 3, 15A, C
			2)	Infection control	Module 6
	THEORY		3)	Safety and emergency procedures including the Heimlich maneuver	Modules 4, 5, 12
			4)	Promoting the independence of patients	Modules 8E, H, 14		TEST
			5)	Respecting the rights of patients	Modules 2, 16C
HOURS	DATE	INITIALS					SCORES

MODULE 1: Introduction

A)Roles and responsibilities of a Certified Nurse Assistant (CNA)

B)Title 22

C)Requirements for nurse assistant certification

D)Professionalism

E)Ethics and confidentiality

MODULE 2: Patients’ Rights

A)Title 22

B)Health and Safety Code

C)Code of Federal Regulations

MODULE 3: Communication / Interpersonal Skills

A)Communications

B)Defense mechanisms

C)Sociocultural factors

D)Attitudes illness / health care

E)Family interaction

MODULE 4: Prevention and Management of Catastrophe and Unusual Occurrences

A)Emergency

B)General safety rules

C)Fire and disaster plans

D)Roles and procedures for CNA

E)Patient safety

MODULE 5: Body Mechanics

A)Basic body mechanics

B)Transfer techniques

C)Ambulation

D)Proper body mechanics / positioning techniques

All records pertaining to individuals who have successfully completed the program shall be available for the Department’s inspection for a period of four (4) years beginning from the date of enrollment. Compliance with the Bureau for Private Postsecondary Education requires that all student records (including those who do not complete the course) must be kept for five (5) years from the date of enrollment.

CDPH 276C (04/14)

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

Page 1 of 3

NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM

INDIVIDUAL STUDENT RECORD

Student Name	Instructor Signature	Initials

	THEORY				TEST
			CONTENT		SCORES
HOURS	DATE	INITIALS
			MODULE 6: Medical and Surgical Asepsis

A)Microorganisms

B)Universal precautions

C)Principles of asepsis

MODULE 7: Weights and Measures

A)Metric system

B)Weight, length, and liquid volume

C)Military time, i.e., a 24-hour clock

MODULE 8: Patient Care Skills

A)Bathing / medicinal baths

B)Dressing

C)Oral hygiene

D)Hair care, shampoo, medicinal shampoo, nail care, shaving

E)Prosthetic devices

F)Skin care / decubitus ulcers

G)Elimination needs

H)Bowel and bladder retraining

I)Weigh and measure patient

MODULE 9: Patient Care Procedures

A)Collection of specimens, including: stool, urine, and sputum

B)Care of patient with tubing, gastric, oxygen, urinary, IV. This care does not include inserting, suctioning, or changing the tubes.

C)I and O

D)Bed making

E)Cleansing enemas, laxative suppositories

F)Admission, transfer, discharge

G)Bandages, nonsterile dry dressing application of nonlegend topical ointments to intact skin

MODULE 10: Vital Signs

A)Purpose of vital signs

B)Factors affecting vital signs

C)Normal ranges

D)Methods of measurement

E)Temperature, pulse, respiration

F)Blood pressure

G)Abnormalities

H)Recording

MODULE 11: Nutrition

A)Proper nutrition

B)Feeding technique

C)Diet therapy

CDPH 276C (04/14)

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

Page 2 of 3

NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM

INDIVIDUAL STUDENT RECORD

Student Name	Instructor Signature	Initials

			THEORY				TEST
	HOURS		DATE		INITIALS	CONTENT	SCORES
						MODULE 12: Emergency Procedures

A)Signs and symptoms of distress

B)Immediate and temporary intervention

C)Emergency codes

MODULE 13: Long-Term Care Resident

A)Needs of persons with retardation, Alzheimer’s, cerebral palsy, epilepsy, dementia, mental illness

B)Introduction to anatomy and physiology

C)Physical and behavioral needs and changes

D)Community resources available

E)Psychological, social, and recreational needs

F)Common diseases / disorders including signs and symptoms

MODULE 14: Rehabilitative Nursing

A)Promoting patient potential

B)Devices and equipment

C)ADLs

D)Family interactions

E)Complications of inactivity

F)Ambulation

G)ROM

MODULE 15: Observation and Charting

A)Observation of patients and reporting responsibilities

B)Patient care plan

C)Patient care documentation

D)Legal issues of charting

E)Medical terminology and abbreviations

MODULE 16: Death and Dying

A)Stages of grief

B)Emotional and spiritual needs of patient and family

C)Rights of dying patient

D)Signs of approaching death

E)Monitoring the patient

F)Postmortem care

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 276C (04/14)

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

Page 3 of 3