CDPH 276C is a form that must be filled out by all medical marijuana dispensary owners in the state of California. This form is used to report information about the dispensary and its employees. Filling out this form accurately is important, as it helps keep track of the dispensaries in the state and ensures that they are following all regulations. dispensary owners should familiarize themselves with this form and make sure they are filling it out correctly.
Question | Answer |
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Form Name | Form Cdph 276C |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | cdph assistant student, 276c form, cdph individual student record, 276c nurse assistant student |
State of California- Health and Human Services Agency
SAMPLE FORM
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
PHONE: (916)
NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM
INDIVIDUAL STUDENT RECORD
TYPE OR PRINT LEGIBLY
Student Name
Social Security Number*
Start Date
Completion Date
Instructor Signature
Printed Name
Initials
Date
Final Grade
Instructor: Date and initial in the theory column when student completes hours.
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CONTENT |
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Prior to any direct contact with a patient, at least a total of sixteen (16) hours of training shall be provided in |
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the following areas: |
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1) |
Communications and interpersonal skills |
Modules 1, 3, 15A, C |
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2) |
Infection control |
Module 6 |
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THEORY |
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3) |
Safety and emergency procedures including the Heimlich maneuver |
Modules 4, 5, 12 |
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4) |
Promoting the independence of patients |
Modules 8E, H, 14 |
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TEST |
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5) |
Respecting the rights of patients |
Modules 2, 16C |
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HOURS |
DATE |
INITIALS |
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SCORES |
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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 |
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NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM
INDIVIDUAL STUDENT RECORD
Student Name |
Instructor Signature |
Initials |
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THEORY |
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TEST |
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CONTENT |
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SCORES |
HOURS |
DATE |
INITIALS |
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MODULE 6: Medical and Surgical Asepsis |
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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
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 |
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THEORY |
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TEST |
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HOURS |
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DATE |
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INITIALS |
CONTENT |
SCORES |
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MODULE 12: Emergency Procedures |
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A)Signs and symptoms of distress
B)Immediate and temporary intervention
C)Emergency codes
MODULE 13:
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
*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 |
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