Form Cdph 283 C - Certified Nurse Assistant (Cna) And/or Home Health Aide (Hha) Renewal Application
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2State of California- Health and Human Services Agency
MAIL OR FAX APPLICATION TO:
California Department of Public Health (CDPH)
CERTIFIED NURSE ASSISTANT (CNA)
Licensing and Certification Program (L&C)
Aide and Technician Certification Section (ATCS)
AND/OR HOME HEALTH AIDE (HHA)
MS 3301, P.O. Box 997416
Sacramento, CA 95899-7416
RENEWAL APPLICATION
PHONE: (916) 327-2445 FAX: (916) 552-8785
EMAIL: cna@cdph.ca.gov
(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.
SECTION I (REQUIRED)
TYPE OF REQUEST
CNA Renewal (complete sections I, II, III, V, and VII)
Certificate number:_________________________
HHA Renewal (complete sections I, II, III, IV, and VII)
Certificate number:_________________________
CNA Reactivation (complete sections I, II, III, V, VI, and VII)
Certificate number:_________________________
SECTION II (REQUIRED)
Last Name
First Name
MI
Sex
Male
Female
Mailing Address (Number and Street or P.O. Box Number)
City
State
Zip Code
Date of Birth
*Social Security Number (SSN)
Driver’s License or State ID Number
Telephone Number
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Number: _____________
State: ___________
*If you use an invalid SSN, your application process may be delayed
SECTION III (REQUIRED)
1)
Subsequent to your last renewal, have you been CONVICTED, at any time, of any crime, other than a minor
Yes
No
traffic violation? (You need not 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)
Subsequent to your last renewal, 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:__________________________________
SECTION IV (IF APPLICABLE)
HHA APPLICANTS ONLY:
3)
I have successfully completed and included documentation of twenty-four (24) hours of In-Service Training/
Yes
No
Continuing Education Units (CEUs) during my most recent certification period. Twelve (12) of the twenty-four
(24) hours were completed in each year of my two (2) year certification period (HHAs may not complete
online CEUs).
SECTION V (IF APPLICABLE)
CNA APPLICANTS ONLY: If you answered “No” to either question number 4 or 5, please go to question 6.
4)
I have successfully completed and included documentation of forty-eight (48) hours of In-Service Training/
Yes
No
CEUs during my most recent certification period. Twelve (12) of the forty-eight (48) hours were completed in
each year of my two (2) year certification period (CNAs may complete a maximum of twenty-four (24) online CEUs).
5)
Have you worked as a CNA in a facility for compensation (under the supervision of a licensed health professional)
Yes
No
within your two (2) year certification period? If you have, check the “Yes” box and provide the facility information
below, as well as list the dates of employment. If you have not, check the “No” box and you may continue to
Section VI.
Facility Name
Telephone Number
Employment Dates
From:
To:
Mailing Address (Number and Street or P.O. Box Number)
City
State
Zip Code
SECTION VI (IF APPLICABLE)
CNA APPLICANTS WHO DID NOT MEET RENEWAL REQUIREMENTS ONLY:
6)
REACTIVATION: I have not completed one (1) or both of the renewal requirements listed above in questions
Yes
No
4 and 5 and wish to reactivate my CNA certificate by taking the Competency Evaluation (see C on the reverse).
If approved, a Competency Evaluation approval letter will be sent to you, along with information to schedule
the evaluation.
SECTION VII (REQUIRED)
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 C (06/15)
This form is available on our website at:
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