Nurse Assistant And/or Home Health Aide Renewal Application Form Page 2

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ADDITIONAL INFORMATION

A. HHA RENEWALS

You may renew your certificate any time within four (4) years after the expiration date of your certificate if, by the time your

certificate expires you will have completed 24 hours of in-service/CE hours (12 hours per 12-months).

B. CNA RENEWALS

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

You submit a completed application to ATCS;

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 a criminal clearance is granted;

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; and

By the time your certificate expires, you will have completed 48 hours of in-service/CE hours. (At least 12 of the 48 hours of

in-service/CE hours shall be completed each year.)

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 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 (Testing). You will not receive certification until the testing vendor (American Red Cross or Nurse Assistant

Training & Assessment Program) notifies ATCS that you passed the competency evaluation and a criminal clearance from the

Department of Justice is obtained.

Note: If you have an active nurse assistant certificate, you may renew at the same time as your HHA. Renewing CNA and HHA

certification together requires a total of 48 in-service training/CE hours. Please maintain records of your in-service/CE hours

and submit to ATCS upon request.

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 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 examination 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 with §483.13 and Title 22 California Code of Regulations,

commencing with §71801.

HS 283 C (5/08) This form is available on our website at: