Form Hs 283 C – Fill Out and Use This PDF

State of California—Health and Human Services Agency				California Department of Health Services
				Licensing and Certification Program (L&C)
				Aide and Technician Certification Section (ATCS)
				1615 Capitol Avenue, MS 3301
				P.O. Box 997416
				Sacramento, CA95899-7416
	NURSE ASSISTANT AND/OR HOME HEALTH AIDE			(916) 327-2445
		RENEWALAPPLICATION
		(Follow instructions on reverse.)
Last name		First name		MI	Sex
					❒ Male	❒ Female
❒ Check here if you wish to have the name changed on your certificate. You must submit a legal document showing the name change.
Mailing address (number and street name or P.O. Box number)			City	State	ZIPcode
Date of birth	*Social Security Number		Driver’s license number	Telephone number
			State:_____________________________
	___ ___ ___ — ___ ___ — ___ ___ ___ ___		Number: __________________________	(	)
TYPE OF REQUEST (Check all applicable.) (See instructions on reverse.)
❒ CNA renewal			❒ Duplicate certificate
Certificate number: ________________________________			CNAnumber: __________________________________
			HHAnumber: __________________________________
❒ HHA renewal

Certificate number: ________________________________

I ❒ have ❒ have not accumulated at least 24 hours of continuing education training hours (12 hours per year).

PROCESSING FEES Returned: $ __________

ALLAPPLICANTS:
1.a. Have you been convicted of any crime since the last time you renewed your certificate
(other than a minor traffic violation)?	❒ No	❒ Yes
b. Has any health-related licensing, certification, or disciplinary authority taken adverse action
(revoked, annulled, cancelled, suspended, etc.) against you? If yes, please indicate the type
and number of license/certificate.	❒ No	❒ Yes

2.CNAAPPLICANTSONLY: I have completed _____ (specify number of hours) of in-service training/continuing education units (CEUs). I will have completed the required 48hours by the expiration date of my certificate.

3. CNAAPPLICANTS ONLY: I ❒ have ❒ have not		worked at least one day, for pay, providing nursing services in the last two years.
List current or most recent employer.
	Employer name		Telephone number		Last date worked
			(	)
	Address (number and street name or P.O. Box number)		City		State	ZIPcode

4.CNAAPPLICANTS ONLY:

❒I want to reactivate my CNA certificate because I cannot meet my renewal requirements listed in numbers 2 and 3 above.

5.HHAAPPLICANTS ONLY:

❒I want to reactivate my HHA certificate. It has been over four years since my HHAcertificate expired.

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

Signature of applicant

Date


Signature of ATCS representative approving applicant for CNAcertificate reactivation only	Date



HS 283C (05/06) This form is available on our website at: http://www.dhs.ca.gov/publications/forms/L&C/l&c.htm

INSTRUCTIONS

A.CNA RENEWALS

You may renew your certificate any time within two years after the expiration date of your certificate if the following applies:

1.You submit a completed application to ATCS;

2.You have been fingerprinted for Certified Nurse Assistant (CNA), Home Health Aide (HHA), Intermediate Care Facility – Developmentally Disabled (ICF–DD), DD Habilitative, or DD Nursing and subsequently cleared for criminal convictions;

3.You provided nursing or nursing-related services to residents in a facility for compensation (i.e. as paid employee, not as a volunteer) within the last two years.

4.You presently or by the time your certificate expires, completed 48 hours of in-service training (at least 12 of the 48 hours of in-service training shall be completed each year). You do not have to submit evidence of obtaining the in-service training, unless you are audited by ATCS.

B.HHA RENEWALS

You may renew your certificate any time within four years after the expiration date of your certificate if:

1.You presently or by the time your certificate expires, completed 24 hours or in-service training (12 hours per 12-months). You do not have to submit evidence of obtaining the in-service training, unless you are audited by ATCS.

C.CNA REACTIVATION

If you are unable to meet the renewal requirements and your certificate has not expired over two years, you may submit this completed application for REACTIVATION without needing re-training.

If you are qualified, ATCS will approve your application for the competency evaluation and will send you information about taking the competency evaluation (i.e. testing). You will not receive certification until the testing vendor (American Red Cross and Nurse Assistant Training & Assessment Program) notifies ATCS that you passed the competency evaluation and you obtain criminal clearance from the Department of Justice.

Certificate Holders with both nurse assistant and home health aide certificates shall renew their certificates at the same time on one application.

INFORMATION COLLECTION AND ACCESS: PRIVACYSTATEMENT

*Social Security Number Disclosure: Pursuant to Section 666(a)(13) of Title 42 of the United States Code and California Family Code, Section17520, subdivision(d), the California Department of Health Services (CDHS) 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 Data Bank as required by 45 CFR §61.1 etseq. Failure to provide your social security number will result in the return of your application. Your social security number will be used by CHDS 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.

Aforementioned requirements are based on Health & Safety Code commencing with §1337 through 1338.5, 1725 through 1742 and 42 Code of Federal Regulations, Chapter IV, commencing wtih §483.13, 483.156, and 483.75, and Title 22 California Code of Regulations, commencing with §71801.

HS 283C (05/06) This form is available on our website at: http://www.dhs.ca.gov/publications/forms/L&C/l&c.htm

OSP06 96238