Hemodialysis Technician Renewal Form – Fill Out and Use This PDF

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)

RENEWAL 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: _______________________
	___ ___ ___ - ___ ___ - ___ ___ ___ ___		Certificate Number
		State: _______________________

If you have a name change, please list below. If your name has changed, you must submit legal proof of the name change (a Social Security Card or Driver’s License are not acceptable as proof of a name change).

Previous Name:	__________________________________________________________________
New Name:	__________________________________________________________________

CHT APPLICANTS:
1)	Has any health-related licensing, certification or disciplinary authority taken	Yes	No
	adverse action (revoked, annulled, cancelled, suspended, etc.) against you?
	-If yes, indicate the type and number of license/certificate:_________________________________________________
2)	In the last four (4) years, have you completed thirty (30) hours of In-Service	Yes	No
	Training/Continuing Education Units (CEUs) and attached copies of the
	certificates of completion with this Renewal Application (CDPH 283 G) as proof?

-CHTs may obtain In-Service Training/CEUs from the following sources: health-related courses offered by accredited postsecondary institutions, health-related courses offered by continuing education providers approved by the California Board of Registered Nursing, health-related courses offered by recognized health associations if the department determines the courses to be acceptable, or health-related employer-sponsored In-Service Training/CEU programs.

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 G (07/12)

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

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CERTIFIED HEMODIALYSIS TECHNICIAN (CHT)

RENEWAL INFORMATION

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

A)Requirements for Renewal

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

2)Must obtain thirty (30) hours of In-Service Training/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).

B)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 G (07/12)

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

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