Form Cdph 283 F PDF Details

For individuals pursuing a career in dialysis care within California, navigating the process of certification can be intricate, and the CDPH 283 F form serves as a fundamental step in achieving professional recognition as a Certified Hemodialysis Technician (CHT). Managed by the California Department of Public Health's Licensing and Certification Program, this form is not only an initial application but a gateway to a specialty where precision and patient care intersect. Applicants must demonstrate their educational background, successful completion of state-approved training programs, and passing scores on relevant examinations, underpinning the rigor and dedication required in the field. Moreover, this form touches upon the renewal process, highlighting the need for continuous learning and adherence to evolving standards through ongoing education requirements. With specific elements emphasizing the safeguarding of public health and personal data, the form underscores the dual focus on professional competence and ethical responsibility. As potential CHTs embark on this journey, understanding the nuances of the CDPH 283 F form is the first step towards a rewarding career that demands both skill and compassion.

QuestionAnswer
Form NameForm Cdph 283 F
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescdph283f cdph lc atcs address 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 EMAIL: cna@cdph.ca.gov

CERTIFIED HEMODIALYSIS TECHNICIAN (CHT)

INITIAL APPLICATION

(See instructions on the reverse)

Last Name

 

First Name

MI

Sex

 

 

 

 

Male Female

 

 

 

 

 

Address (Number and Street or P.O. Box Number)

City

State

Zip Code

 

 

 

 

 

Date of Birth

*Social Security Number (SSN)

Driver’s License Number

Telephone Number

 

 

Number: _______________________

 

 

 

___ ___ ___ - ___ ___ - ___ ___ ___ ___

State: _______________________

 

 

 

 

 

 

 

 

 

 

 

1) Has any health-related licensing, certification or disciplinary authority taken adverse action

Yes

No

(revoked, annulled, cancelled, suspended, etc.) against you?

 

 

-If yes, indicate the type and number of license/certificate:____________________________________

2)EDUCATION

Do you possess a High School Diploma or equivalency (i.e. General EducationYes No Development (GED), High School equivalency, etc.)? You must list the name and address

where you successfully obtained your High School Diploma or equivalency:

Name

Telephone Number

Date/Year Diploma or Equivalency was Obtained

Address (Number and Street or P.O. Box Number)

City

State

Zip Code

Country

3)TRAINING

You must list the name and address of the CHT training program where you successfully completed training:

Name

Telephone Number

Provider Number

Completion Date

Address (Number and Street or P.O. Box Number)

City

State

Zip Code

Country

Printed Name of Registered Nurse (RN) Trainer

Signature of RN Trainer

Date

4)TEST / EXAMINATION

You must list the name and address of the provider where you successfully passed the test / examination:

Name of Test / Examination Provider

Telephone Number

Provider Number

Pass Date

Address (Number and Street or P.O. Box Number)

City

State

Zip Code

Country

Printed Name of Testing / Examination Proctor

Signature of Testing / Examination Proctor

Date

I certify, under penalty of perjury under the laws of the State of California, that the foregoing is true and correct.

_________________________________________________

________________________________

 

Signature of Applicant

 

Date

 

 

 

 

 

 

 

 

CDPH 283 F (07/12)

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

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CERTIFIED HEMODIALYSIS TECHNICIAN (CHT)

GENERAL INFORMATION

A CHT may not perform any duties that require a professional medical or nursing license.

A)Requirements for Initial Certification (must meet all three (3) requirements)

1)Education

a)Have a High School Diploma or equivalency (GED or High School equivalency).

2)Training

a)Have successfully completed a training program that is approved by the medical director and governing body of a Hemodialysis clinic/unit, under the direction of a RN. The training program must be approved by CDPH prior to implementation; OR

b)Have successfully completed a community or corporate-based training program, or a training program offered by an educational institution approved by CDPH.

In addition, you must have passed a written examination offered by a Hemodialysis clinic/unit, or a community or corporate-based training program that meets California law and a skills checklist observed by an RN.

3)Test / Examination

a)Have successfully passed a standardized test that is approved by CDPH; OR

b)Have successfully passed an examination offered by a national commercially available certification program for CHTs, which is approved for this purpose by CMS.

B)Requirements for Renewal

1)Must submit a completed Renewal Application (CDPH 283 G); AND

2)Must obtain thirty (30) hours of In-Service Training/Continuing Education Units (CEUs) in dialysis care or general health care and submit proof of the completed hours with the CDPH 283 G. Applicants must submit copies of their certificates of completion with the CDPH 283 G to verify the In-Service Training/CEU requirement has been met.

No other documentation will be accepted for the In-Service Training/CEU verification purpose. The submission of the completed thirty (30) hours of In-Service Training/CEUs is required, per Business and Professions Code, Division 2, Chapter 3, Article 3.5, Section 1247.63(b).

C)In-Service Training/CEUs

1)CHTs may obtain In-Service Training/CEUs from the following sources:

a)Health-related courses offered by accredited postsecondary institutions (colleges and adult education facilities)

b)Health-related courses offered by continuing education providers approved by the California Board of Registered Nursing

c)Health-related courses offered by recognized health associations if the department determines the courses to be acceptable

d)Health-related employer-sponsored In-Service Training/CEU programs

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 F (07/12)

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

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