Form Hs 283 F – Fill Out and Use This PDF

Last name (and alias)

First name

MI

Sex

Male

Female

Mailing address (No. and Street name or P.O. Box No.)

City

State

ZIP code

Date of birth

*Social Security Number (SSN)

Driver's license number

Telephone number

Month Day

Year

Number:

/

/

CHT Certification Number

State:

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:

Requirements for Certified Hemodialysis Technicians (CHTs): To be certified by CDPH as a Hemodialysis Technician, you must meet three (3) of the following requirements:

1. Education and/or Work Experience (>4 years)
a.) Do you possess a High School (HS) diploma or have you successfully passed an equivalency (e.g.	Yes No
General Education Development (GED), HS Equivalency)?
List the Name and Address where you successfully obtained your HS diploma or Equivalency:

OR

Yes No

b.) Do you possess greater than four (4) years of work experience in dialysis as of October 14, 2008?

List the Name(s) and Address(es) where you acquired greater than four (4) years of work experience in dialysis:

Name	Telephone No.	Date Employed
		From:		To:
Address (No. and Street name or P.O. Box No.)	City	State	Zip Code				Country
Name	Telephone No.	Date Employed
		From:			To:
Address (No. and Street name or P.O. Box No.)	City	State	Zip Code				Country

Note: You may include additional documentation as needed to substantiate your experience.

HS 283 F (10/09) This form is available on our website at: www.cdph.ca.gov

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2.Completion of Training and/or Work Experience (>2 years)

a.) Name of Certified Hemodialysis Training Program where you successfully trained:

Training Program Provider No.

OR

b.) Equivalent Experience in Lieu of Training. If you have no documentation of having successfully completed a training program, and you are currently employed as a hemodialysis technician with more than two (2) years of experience as of October 14, 2008, please complete the following:

Training Program Provider No. (if applicable)

Note: You may include additional documentation as needed to substantiate your experience.

3.Passage of Standardized Test or National Commercially Available Examination approved by the Centers for Medicare and Medicaid Services (CMS).

If yes, indicate the name of provider where you successfully passed the test or examination.

Name of Test or Examination Provider	Telephone No.	Date Passed the Test or Examination
Independent Examiner's Provider No. (if applicable)
Address (No. and Street name or P.O. Box No.)	City	State	Zip Code		Country
Print Name of Proctor who conducted your examination (if applicable)	Signature of Proctor who conducted your examination (if applicable)			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

Incomplete applications will be returned

HS 283 F (10/09) This form is available on our website at: www.cdph.ca.gov

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Initial/Renewal Certified Hemodialysis Technician (CHT) Requirements

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

A.Requirements for Initial Certification

To be certified by the CDPH as a Hemodialysis Technician, you must meet three (3) of the following requirements:

1.Education and/or Work Experience.

a.Have a high school diploma or equivalency (such as a GED or High School Equivalency); OR

b.Have equivalent experience in lieu of HS diploma or equivalency (such as GED or High School Equivalency) greater than four (4) years of work experience in dialysis as of October 14, 2008.

AND

2.Training and/or Work Experience.

a.Have successfully completed a training program that is approved by the medical director and governing body of a hemodialysis clinic or unit, under the direction of a RN. The training program must be approved by the 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 the CDPH; OR

c.If you are unable to provide documentation of successfully passing a training program approved by the CDPH, you may meet this criterion if you are employed as a hemodialysis technician by a hemodialysis clinic or unit for more than two (2) years as of October 14, 2008.

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

AND

3.Passage of Standardized Test or National Commercially Available 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 hemodialysis technicians which is approved for this purpose by the Centers for Medicare and Medicaid Services.

B.Requirements for Renewal

A renewal notice is sent to each CHT approximately four (4) months before his/her certificate expires. However, if the CHT does not receive the notice, it is the responsibility of the CHT to renew his/her certificate in a timely manner.

To apply for renewal, the following must be submitted to ATCS:

1.This completed application.

2.Proof of 30 hours of in-service training or continuing education units (CEUs) taken in the last four (4) years of active certification period.

C.In-Service Training/Continuing Education Requirements

Proof of 30 hours of in-service training/CEUs is required at time of renewal. Original course certifications and/or report cards should be kept by the CHT for four (4) years in the event the CHT is selected for random verification. The in-service training or CEUs must be in dialysis care or general health care.

The CEU requirement may be met through health-related courses offered by the following:

∙Accredited post-secondary institutions (colleges and adult education)

∙Continuing education providers approved by California Board of Registered Nurses and other recognized health associations

∙Employer-sponsored in-service training or continuing education 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 §§ 66.1 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.

Aforementioned requirements are based on Business and Professions Code Sections 1247 to 1247.9.

HS 283 F (10/09) This form is available on our website at: www.cdph.ca.gov

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