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The Cdph Cna form, officially known as the Certified Nurse Assistant (CNA) Initial Application, plays a crucial role in the pathway to becoming a certified nursing assistant in California. This comprehensive document is designed for individuals enrolling in a CNA training program, those with equivalent training, or applicants seeking certification reciprocity from another state. The application includes essential sections where individuals must provide personal information, training details, and background checks related to criminal history. Importantly, the completion of this form is a prerequisite for those looking to enter a CDPH-approved training program or to transfer their certification from another state. Notably, applicants are required to certify the accuracy of their information under penalty of perjury, emphasizing the importance of honesty throughout the application process. The form also includes instructions for additional documentation, such as proof of training or work experience, which must be submitted to the California Department of Public Health. As an integral part of California's healthcare system, the application ensures that all prospective CNAs meet the necessary qualifications and comply with legal standards prior to certification. By understanding the various components and requirements of the Cdph Cna form, applicants can navigate this critical step in their healthcare careers with confidence.

Cdph Cna Example

State of California- Health and Human Services Agency

CERTIFIED NURSE ASSISTANT (CNA)

INITIAL APPLICATION

(See instructions on the reverse)

MAIL OR FAX APPLICATION TO:

California Department of Public Health (CDPH) 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

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

Check here if you are enrolling in a CNA training program (complete sections I, II, III, IV, and V) Check here if you have EQUIVALENT TRAINING (complete sections I, II, III, and V)

Check here if you are requesting RECIPROCITY FROM ANOTHER STATE (complete sections I, II, III, and V) Indicate Transferring State:

SECTION II (REQUIRED)

 

Last Name

First Name

MI

Sex

 

 

 

 

 

 

Male

Female

 

 

Public Address (Required) - Subject to Public Records Act request release *

City

State

Zip Code

 

 

 

 

 

 

 

 

 

Confidential Address (For CDPH use only, If left blank all departmental mail will be sent to address above)

City

State

Zip Code

Date of Birth

Social Security Number** (SSN) or Individual Taxpayer Identification Number (ITIN)

Driver’s License or State ID Number

Number: ________________ State: _________

Email Address***

Phone Number***

Check if this is a

cell phone

 

*Pursuant to a court order, the California Department of Public Health will be required to release the address of record for certified nurse assistants, home health aides, certified hemodialysis technicians, and licensed nursing home administrators in response to a Public Records Act (PRA) request. (Government Code starting at section 6250.) Court Order: Service Employees International Union-United Healthcare Workers v. California Department of Public Health, Sacramento County Superior Court, February 21, 2018, No. 34-2017-80002636.**If you use an invalid SSN, your application process may be delayed ***Providing your telephone number and email address is for the California Department of Public Health's internal use only for contacting applicants. This information will not be released to the public nor will it be displayed online.

SECTION III (REQUIRED)

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,

cancelled, suspended, etc.) against you?

Yes

No

 

-If yes, indicate the type and number of license/certificate:__________________________________

SECTION IV (IF APPLICABLE)

Name of school or facility where you received / will receive the CNA training

Telephone Number

Mailing Address (Number and Street or P.O. Box Number)

City

State

Zip Code

California Training Program ID Number for CNA (Required)

CNA:_________________

Beginning Date of CNA Training

End Date of CNA Training

SECTION V (REQUIRED)

I certify under penalty and perjury under the state and federal laws that the information contained in this application and supporting documents, is true and correct. It shall be unlawful for any person not certified under Health and Safety Code (1200 - 1797.8) to hold himself or herself out to be a certified nurse assistant.

____________________________________________________________

________________________________________

Signature

Date

 

SECTION VI: TO BE COMPLETED BY THE REGISTERED NURSE RESPONSIBLE FOR THE GENERAL 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

FOR VENDOR USE ONLY

 

CDPH 283 B (08/19)

This form is available on our website at: www.cdph.ca.gov

Page 1 of 2

 

 

Email inquiries only: [email protected]

 

CERTIFIED NURSE ASSISTANT (CNA)

INITIAL APPLICATION INFORMATION

CRIMINAL RECORD CLEARANCE

Upon enrollment in a CDPH-approved training program, the applicant must be fingerprinted through the Live Scan process.

All convictions are reviewed. If the conviction prevents certification, the applicant will be notified. Applicants will not receive a certificate until they have received a criminal record clearance.

A)CNA APPLICANTS (complete sections I, II, III, IV, and V)

1)The applicant must submit the following to ATCS upon enrollment in the program and before patient contact:

a)This completed Initial Application (CDPH 283 B); and

b)The second copy of the completed Request for Live Scan Services (BCIA 8016) form.

B)EQUIVALENCY-TRAINED NURSE ASSISTANT APPLICANTS (complete sections I, II, III, and V)

1)If the applicant is presently enrolled in (or completed) a Registered Nurse, Licensed Vocational Nurse, or Licensed Psychiatric Technician program, or has received medical training in military services, or has received the above license(s) from a foreign country or U.S. state, the applicant may not have to take further training and may qualify to take the Competency Evaluation. Please submit the following to ATCS:

a)This completed Initial Application (CDPH 283 B). If approved, the applicant will be sent information regarding the Competency Evaluation.

b)An official, sealed transcript of training (students may substitute the transcript with a sealed letter on official school letterhead, listing equivalent training and the completion of at least the "Fundamentals of Nursing" course). The letter must include the completion date(s) of the training/courses and hours/units completed. If discharged from the military, a copy of the DD-214 can substitute for an official transcript. If seeking certification with the use of a foreign transcript, a copy of the foreign transcript may be acceptable; and

c)Proof of work (paystub or W2) showing the applicant has provided nursing or nursing-related services in a facility to residents for compensation within the last two (2) years (not required for current nursing students or if the college degree was obtained within the last two (2) years); and

d)A copy of the completed Request for Live Scan Services (BCIA 8016) form.

C) RECIPROCITY APPLICANTS (complete sections I, II, III, and V)

1)If the CNA certification is active and in good standing on another state's registry, the applicant may qualify for certification in the State of California without taking CNA training or the Competency Evaluation. Please submit the following to ATCS:

a)This completed Initial Application (CDPH 283 B).

b)A copy of the state-issued certificate; and

c)Proof of work (paystub or W2) showing the CNA has provided nursing or nursing-related services in a facility to residents for compensation within the last two (2) years (not required for those who received their initial certification from another state within the last two (2) years); and

d)A copy of the completed Request for Live Scan Services (BCIA 8016) form. The applicant must be fingerprinted in the State of California to obtain criminal record clearance through this method; and

e)A completed Verification of Current Nurse Assistant Certification (CDPH 931) form, which must be completed by the applicant and submitted by the endorsing state agency.

D) CNA RENEWAL INFORMATION

1)The initial CNA certificate is issued for two birthdays, not two calendar years, and will expire on your birthday. Each year of the certification period will be from one birthday to the following birthday. Any additional time from the effective date until the first birthday will be counted towards the first year of the certification period. CNA certificates must be renewed every two (2) years. You may renew your certificate any time within two (2) years after the expiration date, if by the time the certificate expires you will have completed the following:

a)You have previously received and maintained criminal record clearance for CNA, HHA, Intermediate Care Facility- Developmentally Disabled (ICF-DD), DD Habilitative, or DD Nursing and a criminal clearance is granted; and

b)You have provided nursing or nursing-related services in a health facility to residents for compensation (under the supervision of a licensed health professional) within your most recent certification period; and

c)You have successfully obtained and submitted documentation of forty-eight (48) hours of In-Service Training (provided by the Skilled Nursing Facility-SNF employer or Home Health Agency – HHA employer or Continuing Education Units (CEUs) (provided by a non-SNF/HHA employer) within your most recent certification period. The SNF In-Service documentation must be submitted on the CDPH 283A form, including the signature of the instructor responsible for the training. Only CDPH-approved CEU providers with a Nurse Assistant Certification Number (NAC#) may provide CEUs for CNAs. CEU certificates must be submitted with the renewal application. Twelve (12) of the forty-eight (48) hours shall be completed in each year of the two (2) year certification period. A maximum of twenty-four (24) of the forty-eight (48) hours may be obtained only through a CDPH-approved online computer training program listed on our website. Please visit www.cdph.ca.gov for a complete listing of CDPH-approved online CEU computer training programs and CDPH-approved classroom CEU providers.

E) FAILURE TO RENEW PRIOR TO THE EXPIRATION DATE ON THE CERTIFICATE

1)Certificate holders who fail to renew prior to the expiration date on the certifcate will be placed in a delinquent status. These individuals will not be verifiable online until the applicant meets all the renewal requirements within the most recent two year certification period. Individuals in a delinquent status may not hold himself or herself out to be a CNA until the certificate is renewed and in active status.

2)Due to the lapse in certifcation the effective date will be changed to the date the application was renewed.

F) NAME AND ADDRESS CHANGES

1)Certificate holders shall notify CDPH within sixty (60) days of any change of address. If requesting 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.

Aforementioned requirements are based on Health and Safety Code commencing with §1337 through 1338.5, 1725 through 1742 and Code of Federal Regulations Title 42, Chapter IV, commencing with §483.13 and California Code of Regulations, Title 22, commencing with §71801.

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 Department of Child Support Services and for reporting disciplinary actions to 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 exam identification, for identification purposes in national disciplinary databases or as the basis of a disciplinary action against you.

 

CDPH 283 B (08/19)

This form is available on our website at: www.cdph.ca.gov

Page 2 of 2

 

 

Email inquiries only: [email protected]

 

File Breakdown

Fact Name Details
Governing Law The CNA application process is governed by the California Health and Safety Code, Sections 1200 through 1797.8.
No Processing Fee Applicants do not need to pay a fee to process their CNA application.
Required Sections Sections I, II, III, and V of the application must be completed for all applicants.
Criminal Record Clearance Applicants must be fingerprinted through the Live Scan process for criminal record clearance before certification is granted.
Renewal Requirements CNA certificates must be renewed every two years and require completion of specific training hours and verification of work experience.

Guide to Using Cdph Cna

Completing the California Department of Public Health's Certified Nurse Assistant (CNA) Initial Application form can seem daunting, but following a systematic approach will simplify the process. Gather all necessary information and materials before you begin to ensure you fill out the form accurately and completely. This will help speed up the processing of your application.

  1. Obtain the CNA Initial Application form (CDPH 283 B).
  2. Read the instructions carefully to understand the requirements.
  3. Determine the type of request you are making and check the appropriate box in Section I. Choose from options like enrolling in a training program, declaring equivalent training, or requesting reciprocity from another state.
  4. In Section II, fill in your personal details, including your last name, first name, middle initial, date of birth, and Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN).
  5. Provide your public address, city, state, and zip code. If you want a confidential address (for CDPH use only), fill that out as well.
  6. Indicate your driver’s license or state ID number, email address, and phone number. You can check if it’s a cell phone.
  7. Complete Section III by answering questions regarding any criminal convictions or health-related licensing actions against you. Provide additional details if necessary.
  8. If applicable, complete Section IV by providing the name of your CNA training facility, contact number, mailing address, and California Training Program ID number. Fill out the starting and ending dates for your CNA training.
  9. In Section V, certify that all the information provided is true by signing and dating the form.
  10. If you are a student who has completed a CNA training program in California, a registered nurse must complete Section VI. This includes their printed name, title, signature, and date.
  11. Review the completed application to ensure all sections are filled out correctly and all information is accurate.
  12. Mail or fax your completed application to the specified address: California Department of Public Health, Licensing and Certification Program, Aide and Technician Certification Section, MS 3301, P.O. Box 997416, Sacramento, CA 95899-7416. Alternatively, you can fax it to (916) 552-8785.

Once submitted, your application will be processed. You will receive further communications from the California Department of Public Health regarding the next steps, including any additional documentation that may be required. Ensure you remain reachable by the contact information provided.

Get Answers on Cdph Cna

  1. What is the purpose of the CDPH CNA form?

    The CDPH CNA form is necessary for individuals who wish to apply for certification as a Certified Nurse Assistant (CNA) in California. It enables applicants to enroll in CNA training programs, request reciprocity from another state, or show equivalent training. Proper completion of this form is vital for processing the application.

  2. What sections must I complete in the form?

    All applicants must fill out Sections I, II, III, and V. Section I pertains to the type of request, and Section II captures personal and identifying information. Section III evaluates any criminal record or disciplinary actions. Additional sections may apply based on the specific qualification being pursued, such as Sections IV for those in training programs.

  3. Is there a fee to process this application?

    No, there is no fee associated with submitting the CDPH CNA form. This process is entirely free for applicants as they take their steps toward becoming certified nurse assistants.

  4. What happens if I do not answer all applicable questions?

    Your application will not be processed if all relevant questions are left unanswered. It is crucial to provide complete and accurate information to avoid delays or rejection of the application.

  5. What is required for criminal record clearance?

    Upon enrolling in a CDPH-approved training program, applicants must undergo fingerprinting via the Live Scan process. All convictions will be reviewed, and if a conviction prevents certification, applicants will be notified. Criminal record clearance must be obtained before receiving certification.

  6. What documents do I need to submit when seeking reciprocity from another state?

    Applicants seeking reciprocity must submit the following:

    • The completed Initial Application (CDPH 283 B).
    • A copy of the active state-issued certificate.
    • Proof of work, such as a paystub or W2, showing the provision of nursing-related services within the last two years.
    • A copy of the completed Request for Live Scan Services (BCIA 8016) form.
    • A completed Verification of Current Nurse Assistant Certification (CDPH 931) form from the endorsing state agency.
  7. How often must a CNA certificate be renewed?

    The CNA certificate must be renewed every two years. The initial certificate is valid until the next birthday after issuance, after which expiration occurs annually on the birthday. Renewals can be submitted any time within two years after expiration, provided certain training and service requirements have been satisfied during that period.

  8. What should I do if I change my name or address?

    Certificate holders must notify the CDPH within sixty days of any address change. For name changes, legal documentation such as a marriage certificate or court documents is required. Failure to report these changes can result in delays or issues with certification.

Common mistakes

When filling out the Certified Nurse Assistant (CNA) Initial Application form, applicants can make several common mistakes that may delay the processing of their application. One frequent error is failing to complete all applicable sections. Each section of the form must be filled out as required, or it will not be processed. This includes personal information, training details, and any pertinent legal history.

Another mistake often made involves providing incorrect or incomplete personal information. For instance, omitting the Social Security Number can lead to significant delays. Valid personal identification is essential for the application to be considered, so it is crucial to double-check that this information is accurate and fully provided.

Many applicants also wrongly assume that answering “no” to all questions in Section III regarding past criminal convictions will suffice. This section demands attention. If there has been any conviction other than a minor traffic violation—even if it seems insignificant—it should be disclosed. Misrepresenting or omitting this can not only prevent certification but also may lead to further legal repercussions in the future.

Another pitfall is failing to accurately indicate the type of request in Section I. Whether enrolling in a training program, seeking reciprocity, or claiming equivalent training, the right box must be checked. Not doing so can send the application in the wrong direction right from the start.

Furthermore, applicants often overlook the importance of their contact information. Providing an email address and phone number is not only beneficial but necessary for communication with the California Department of Public Health (CDPH). Ensure that these details are current and clearly stated. This allows for prompt updates regarding the application status.

In Section IV, crucial training information must also be carefully filled out. Forgetting to include the California Training Program ID Number may result in the application being flagged for additional review. The dates of CNA training should also be accurately recorded to avoid confusion regarding completion status.

Furthermore, many people neglect to sign and date the application in Section V. A signature signifies affirming the truthfulness of the information provided. Skipping this step renders the application incomplete, leading to immediate rejection.

Lastly, there is often confusion regarding the process for submitting additional documents, like the Request for Live Scan Services form. Not submitting this along with the application can cause cascading delays in the approval process. Thoroughly review the requirements to ensure all necessary documents are submitted collaboratively with the initial application.

Documents used along the form

The Certified Nurse Assistant (CNA) Initial Application (CDPH CNA form) is crucial for individuals aiming to become certified in California. Alongside this form, several other documents and forms are often required during the application and certification process. Each plays an important role in ensuring applicants meet the required standards and guidelines for certification. Below is a list of these forms, each accompanied by a brief description.

  • Request for Live Scan Services (BCIA 8016): This form is necessary for applicants to undergo the fingerprinting process. It ensures a background check is conducted, which is vital for obtaining a criminal record clearance.
  • Verification of Current Nurse Assistant Certification (CDPH 931): This document is needed for applicants requesting reciprocity from another state. It must be completed by the certifying agency in the applicant's previous state and verifies the certification status.
  • Training Program Information: While not a single form, this information includes the name and contact details of the training facility where the applicant received or will receive their CNA training. It must be included in the application to validate the training credentials.
  • Official Transcript or Equivalent Training Letter: Applicants with equivalent training must provide a sealed transcript or a letter from their training institution. This document must outline the training received and confirm completion of essential courses, such as Fundamentals of Nursing.
  • Proof of Work Documentation: Required for various applicant categories, this includes a recent paystub or W-2. It shows that the applicant has provided nursing or nursing-related services within the last two years, which is necessary for both new and reciprocity applicants.
  • CNA Renewal Application (CDPH 283 A): For those already certified, this document is used to renew CNA certification every two years. It requires documentation of continuing education and clinical experience during the certification period.
  • Name Change Documentation: If an applicant wishes to change their name in their certification, they must submit legal verification. Acceptable forms of verification include a marriage certificate, divorce decree, or appropriate court documents to validate the name change.
  • Address Change Notification: Certificate holders must inform the Department of Public Health within sixty days of any address changes. This ensures that all records remain current and accessible.

These forms and documents collectively ensure a streamlined certification process that protects the integrity of the nursing assistant profession. Being thorough and timely in completing these requirements can significantly impact an applicant’s journey toward becoming a certified nurse assistant in California.

Similar forms

The CDPH CNA form shares important similarities with several other documents frequently used in healthcare certification and application processes. Each of these documents serves a unique purpose, yet they follow a similar structure and requirements. Here’s a closer look at these documents:

  • Nursing License Application: This document is used by individuals seeking a nursing license. Like the CNA form, it requires personal information, educational background, and criminal history disclosure.
  • Certified Home Health Aide (HHA) Application: Similar to the CNA application, the HHA application mandates personal and training information, as well as background checks before approval for certification.
  • Certified Medical Assistant (CMA) Application: Those applying for a CMA position must complete forms that ask for educational credentials, work history, and a declaration of any past disciplinary actions, paralleling the structure of the CNA form.
  • Licensed Vocational Nurse (LVN) Application: This application requires detailed personal information, proof of nursing education, and verification of a clean criminal record, resembling the requirements found in the CNA form.
  • CPR Certification Application: Like the CNA application, this document necessitates proof of training and background information, ensuring applicants meet specific standards in their qualifications.
  • Occupational Therapy Assistant Certification Application: This certification process involves sections asking for similar data, such as personal identification, educational history, and any legal issues that could impact the applicant’s eligibility.
  • Emergency Medical Technician (EMT) Application: Applicants for EMT certification are required to provide personal information and details regarding their training and any prior health-related certifications, mirroring the methodical approach of the CNA form.
  • Physical Therapy Assistant Certification Application: Much like the CNA document, this form requires applicants to supply details about their training, certifications, and background checks prior to obtaining certification.
  • Pharmacy Technician Registration Application: This application asks for personal identification, educational completion, and any relevant criminal disclosures, echoing the format utilized in the CNA form.

Understanding these parallels can help applicants navigate the requirements more effectively, ensuring they are adequately prepared for each submission process.

Dos and Don'ts

  • Do: Provide accurate information.
  • Do: Complete all required sections, including personal details.
  • Do: Submit supporting documents as instructed.
  • Do: Sign and date the application before submission.
  • Do: Contact the CDPH if you have any questions.
  • Don't: Leave any required sections blank.
  • Don't: Use an invalid Social Security Number (SSN).
  • Don't: Forget to provide a phone number and email for contact.
  • Don't: Wait until the deadline to submit your application.
  • Don't: Assume your application will be processed without all required information.

Misconceptions

When navigating the process of applying for a Certified Nurse Assistant (CNA) credential in California, misunderstandings can arise. Here are eight common misconceptions about the CDPH CNA form, along with clarifications to enhance understanding.

  • There is a fee to submit the application. This is false. Submitting the CDPH CNA form is completely free. Applicants should not worry about application fees delaying their process.
  • Only individuals with nursing degrees can apply. This is not true. Any eligible individual can apply as long as they meet the necessary training requirements, which can include approved CNA training programs or equivalent training.
  • Fingerprints are optional for the application process. In fact, applicants must complete the Live Scan fingerprinting process. This is a mandatory step for all prospective CNAs.
  • All criminal convictions disqualify someone from certification. This is misleading. While certain convictions could affect eligibility, minor traffic violations and specific marijuana-related offenses are exempt from disclosure.
  • Email and phone number provided will be publicly accessible. On the contrary, this information is kept confidential. It is solely for internal use to assist in contacting applicants.
  • Once certified, CNS don’t need to renew their certification. This assumption is incorrect. CNAs must renew their certification every two years to maintain their active status.
  • You can change your information without notifying CDPH. In reality, applicants must report any name or address changes within 60 days. Failing to do so can result in delays or certification issues.
  • Submitting an application starts the certification process immediately. This is a misconception. The processing time will vary, and all sections of the application must be completed thoroughly for it to be processed efficiently.

Understanding these misconceptions can help streamline the application process for aspiring CNAs. By being informed, applicants can avoid unnecessary pitfalls and facilitate a smoother path to certification.

Key takeaways

  • Application Submission: You can mail or fax the CDPH CNA form to the California Department of Public Health. Make sure to include all required sections and information.
  • No Processing Fee: There is no fee associated with submitting the application. This means you can complete your request without worrying about additional costs.
  • Complete All Questions: Ensure that every applicable question is answered. An incomplete application may not be processed at all, causing delays.
  • Certain Information is Confidential: Your personal details like phone number and email will not be released to the public. However, your public address will be subject to the Public Records Act.
  • Criminal Record Clearance: Before starting direct patient care, you must undergo fingerprinting for criminal record clearance. This step is mandatory for all applicants.