The California Department of Public Health (CDPH) released a new form, Form CDPH 283F, to be used for notifying the department about suspected cases of foodborne illness. The form is available on the CDPH website and must be completed by health care providers, laboratories, and local environmental health agencies. The notification should include information about the illness or outbreak, such as dates of symptom onset, diagnosis, and laboratory results. Providers are also encouraged to report any related deaths.
| Question | Answer |
|---|---|
| Form Name | Form Cdph 283 F |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | cdph283f cdph lc atcs address form |
State of California- Health and Human Services Agency |
California Department of Public Health (CDPH) |
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Licensing and Certification Program (L&C) |
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Aide and Technician Certification Section (ATCS) |
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MS 3301, P.O. Box 997416 |
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Sacramento, CA |
PHONE: (916) |
FAX: (916) |
CERTIFIED HEMODIALYSIS TECHNICIAN (CHT)
INITIAL APPLICATION
(See instructions on the reverse)
Last Name |
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First Name |
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Sex |
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Address (Number and Street or P.O. Box Number) |
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State |
Zip Code |
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Date of Birth |
*Social Security Number (SSN) |
Driver’s License Number |
Telephone Number |
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Number: _______________________ |
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State: _______________________ |
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1) Has any |
Yes |
No |
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(revoked, annulled, cancelled, suspended, etc.) against you? |
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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.
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Signature of Applicant |
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Date |
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CDPH 283 F (07/12) |
This form is available on our website at: www.cdph.ca.gov |
Page 1 of 2 |
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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
In addition, you must have passed a written examination offered by a Hemodialysis clinic/unit, or a community or
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
No other documentation will be accepted for the
C)
1)CHTs may obtain
a)
b)
c)
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 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 |
Page 2 of 2 |