Form Cdph 283 B - Certified Nurse Assistant (Cna) And/or Home Health Aide (Hha) Initial Application
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2California 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)
MS 3301, P.O. Box 997416
Sacramento, CA 95899-7416
PHONE: (916) 327-2445 FAX: (916) 552-8785 EMAIL: cna@cdph.ca.gov
CERTIFIED NURSE ASSISTANT (CNA)
AND/OR HOME HEALTH AIDE (HHA)
INITIAL APPLICATION
(See instructions on the reverse)
THERE IS NO FEE TO PROCESS THIS APPLICATION. YOUR APPLICATION WILL NOT BE PROCESSED IF ALL APPLICABLE QUESTIONS ARE NOT ANSWERED.
Last Name
First Name
MI
Sex
Male
Female
Mailing Address (Number and Street or P.O. Box Number)
City
State
Zip Code
Driver’s License or State ID Number
Date of Birth
*Social Security Number (SSN)
Telephone Number
Number: _______________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
State:
_______________________
Height
Weight
Hair Color
Eye Color
*If you use an invalid SSN, your application will not be processed.
1)
Have you been CONVICTED, at any time, of any crime, other than a minor traffic violation? (You need not
Yes
No
disclose any marijuana-related offenses specified in the marijuana reform legislation and codified at the
Health and Safety Code, Sections 11361.5 and 11361.7).
-
If yes, list conviction:________________________ Court of conviction:______________________ Date:________________
2)
Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled,
Yes
No
cancelled, suspended, etc.) against you?
-
If yes, indicate the type and number of license/certificate:__________________________________
TYPE OF REQUEST (See A or B on the reverse.)
Check here if you are enrolling in a CNA training program and complete the school portion below.
Check here if you are enrolling in a HHA training program and complete the school portion below.
Name of school or facility where you received / will receive the CNA or HHA training
Telephone Number
Ventura College School of Nursing and Allied Health
(805) 289-6342
Mailing Address (Number and Street or P.O. Box Number)
City
State
Zip Code
4667 Telegraph Road
Ventura
CA
93003
California Training Program ID Number(s) (Required)
Beginning Date of Training
End Date of Training
50785
548
Nurse Assistant:______________________ Home Health Aide:______________________
Check here if you have EQUIVALENT TRAINING. (See C on the reverse.)
Check here if you are requesting RECIPROCITY FROM ANOTHER STATE.
State:______________ (See D on the reverse.)
NAME AND ADDRESS CHANGES: Certificate holders shall notify CDPH within sixty (60) days of any change of address. If you have had
a name change, submit legal verification of the change (marriage certificate, divorce decree, or court documents). Failure to report a name
or address change may result in the delay or loss of your certification.
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
TO BE COMPLETED BY THE REGISTERED NURSE (RN) RESPONSIBLE FOR THE GENERAL
FOR VENDOR USE ONLY
SUPERVISION OF THE TRAINING PROGRAM: I certify that this individual has successfully
completed state and federal nurse assistant training requirements and is eligible to take the
Competency Evaluation (this section only applies to students that have recently completed a CNA
Training Program in California).
______________________________________
_______________________
Printed Name
Title
______________________________________
_______________________
Signature
Date
CDPH 283 B (03/13)
This form is available on our website at:
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