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

Download a blank fillable Certified Nurse Assistant And/or Home Health Aide Renewal Application Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Certified Nurse Assistant And/or Home Health Aide Renewal Application Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADDITIONAL INFORMATION

CNA RENEWALS

You may submit a renewal application any time within two (2) years after the expiration date of your certificate, if by the time your

certificate expires you will have completed the following:

You have previously received and maintained clearance for Certified Nurse Assistant (CNA), Home Health Aide (HHA),

●

Intermediate Care Facility- Developmentally Disabled (ICF-DD), DD Habilitative, or DD Nursing and a criminal record

clearance is granted; and

You provided nursing or nursing-related services to residents in a facility for compensation (under the supervision of a

●

licensed health professional) within your most recent certification period; and

You have successfully completed forty-eight (48) hours of in-service/CE hours. (At least twelve (12) of the forty-eight (48)

●

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

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 have completed twenty-four (24) hours of in-service/CE hours (twelve (12) hours per twelve (12) months).

If you have an active CNA certificate, you may renew at the same time as your HHA. Renewing CNA and HHA certification together

requires a total of forty-eight (48) in-service training/CE hours. Please maintain records of your in-service/CE hours and submit to ATCS

upon request.

C. CNA REACTIVATION

If you are unable to meet the renewal requirements and your certificate has not expired over two (2) 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 National Nurse Aide

Assessment Program) notifies ATCS that you have successfully passed the competency evaluation and you have maintained criminal

record clearance.

*NAME AND ADDRESS CHANGES*

The CNA/HHA is responsible for notifying ATCS, within sixty (60) days, whenever changes of their name, address, or telephone number

occur. If they have had a name change, they must submit legal verification of the change. Indicate the certificate number or SSN for

identification purposes. Failure to do so could result in the delay or loss of the certification.

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.

CDPH 283C (06/11) This form is available on our website at: