Form Hs 283 F PDF Details

The Department of Homeland Security's Form HS 283 provides the steps for submitting a security threat assessment (STA) request. The form can be used by individuals or organizations who need to determine if someone is eligible to receive a visa, work permit, or other immigration benefit. The STA process helps protect against potential threats by ensuring that those who pose a danger to the United States are not granted access. Today we'll walk you through how to complete Form HS 283 F and submit your request.

QuestionAnswer
Form NameForm Hs 283 F
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesLNC AFL 09 43 Attach HS283F initial cht application form

Form Preview Example

State of California-Health and Human Services Agency

CERTIFIED HEMODIALYSIS TECHNICIAN

INITIAL/RENEWAL APPLICATION

(See requirements on page 3)

PRINT 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 95899-7416

(916)327-2445 FAX (916) 552-8785 cna@cdph.ca.gov

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:

 

Name

Telephone No.

Date and/or Year obtained diploma or equivalency

Address (No. and Street name or P.O. Box No.)

City

State

Zip Code

Country

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

Page 1 of 3

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

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

Name

Telephone No.

Date Program Completed:

Training Program Provider No.

Address (No. and Street name or P.O. Box No.)

City

State

Zip Code

Country

Print Name of Registered Nurse (RN) Trainer

Signature of RN Trainer

Date

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:

Name of Dialysis Clinic or Unit

Telephone No.

Date employed at Dialysis Clinic or Unit

From:To:

Training Program Provider No. (if applicable)

Address (No. and Street name or P.O. Box No.)

City

State

Zip Code

Country

Print Name of Registered Nurse (RN) who conducted your examination

Signature of RN who conducted your examination

Date

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).

a.) Did you successfully pass a Standardized Test in California?

OR

b.) Did you successfully pass a National Commercially Available Examination approved by the Centers for Medicare and Medicaid Services (CMS)? (See Page 3)

Yes No

Yes No

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

Page 2 of 3

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

Page 3 of 3

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This document requires particular information to be filled in, therefore be sure you take some time to provide what is requested:

1. To get started, when filling in the Form Hs 283 F, start in the part that contains the next blank fields:

Step no. 1 for submitting Form Hs 283 F

2. After filling in the last section, go to the next step and enter all required details in all these blank fields - Address No and Street name or PO, City, State, Zip Code, Country, Yes, b Do you possess greater than four, Name, Telephone No, Date Employed, Address No and Street name or PO, City, From, State, and Zip Code.

Form Hs 283 F conclusion process clarified (step 2)

3. In this particular stage, take a look at Name, Telephone No, Date Program Completed, Training Program Provider No, Address No and Street name or PO, City, State, Zip Code, Country, Print Name of Registered Nurse RN, Signature of RN Trainer, Date, b Equivalent Experience in Lieu of, Date employed at Dialysis Clinic, and Telephone No. All these are required to be filled in with highest accuracy.

Filling out segment 3 of Form Hs 283 F

Always be extremely mindful while completing City and Country, because this is the part where most users make mistakes.

4. The subsequent paragraph needs your input in the following places: a Did you successfully pass a, Medicare and Medicaid Services CMS, If yes indicate the name of, Yes, Yes, Name of Test or Examination, Telephone No, Date Passed the Test or Examination, Independent Examiners Provider No, Address No and Street name or PO, City, State, Zip Code, Country, and Print Name of Proctor who. Always give all requested info to move onward.

Yes, a Did you successfully pass a, and Zip Code of Form Hs 283 F

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