Nurse Assistant And/or Home Health Aide Renewal Application Form

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California Department of Public Health (CDPH)
State of California—Health and Human Services Agency
Licensing and Certification Program (L&C)
Aide and Technician Certification Section (ATCS)
1615 Capitol Avenue, MS 3301
NURSE ASSISTANT AND/OR HOME HEALTH AIDE
P.O. Box 997416
Sacramento, CA 95899-7416
RENEWAL APPLICATION
(916) 327-2445 FAX (916) 552-8785
cna@cdph.ca.gov
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
ZIP code
Date of birth
*Social Security Number
Driver's license number
Telephone number
State:
(
)
___ ___ ___ — ___ ___ — ___ ___ ___ ___
Number:
(See additional information on back of this form.)
TYPE OF REQUEST (Check all applicable.)
HHA Renewal
CNA Renewal
Certificate number: ________________________________
Certificate number: ________________________________
ALL APPLICANTS:
Have you been convicted of any crime (i.e. felony, misdemeanor, infraction) since the last time you
1.
Yes
No
renewed your certificate? (other than a minor traffic violation)
Has any health-related licensing, certification, or disciplinary authority taken adverse action (revoked, annulled,
2.
Yes
No
cancelled, suspended, etc.) against you?
If yes, please indicate the type and license/certificate number.
HHA APPLICANTS ONLY:
I have successfully completed 24 hours of in-service/continuing education (CE) hours during my last certification
3.
Yes
No
period. (12 hours per year.)
CNA APPLICANTS ONLY:
4.
I have successfully completed 48 hours of in-service/CE hours during my present certification period.
Yes
No
I have not completed 48 hours of in-service/CE hours but I will complete the required 48 hours by the expiration
5.
Yes
No
date of my certificate.
- If you marked Yes to question 5, please indicate in the box the number of in-service/CE hours that you have
completed to date.
I have provided nursing or nursing-related services in a facility to residents for compensation within the last two years.
6.
Yes
No
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
ZIP code
REACTIVATION:
7.
CNA APPLICANTS ONLY: I have not/cannot meet both renewal requirements listed above (Questions 4, 5 and 6);
therefore, I wish to reactivate my CNA certificate by passing the competency evaluation (Testing).
Yes
No
(Please review Section C on the back of this application. Testing information will be sent to you.)
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
Signature of ATCS representative approving applicant for CNA certificate reactivation only
Date
HS 283 C (5/08)
This form is available on our website at:

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