State of California—Health and Human Services Agency
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
(916) 327-2445 FAX (916) 552-8785
CERTIFIED NURSE ASSISTANT
AND/OR HOME HEALTH AIDE
RENEWAL APPLICATION
Last name First name MI Sex
Check here if you wish to have the name changed on your certificate. You must submit a legal document showing the name change.
Mailing address (number and street name or P.O. Box number)
City State ZIP code
Date of birth *Social Security Number Telephone number
___ ___ ___ — ___ ___ — ___ ___ ___ ___
TYPE OF REQUEST (Check all that apply. See additional information on back of this form.)
Certificate number: ________________________________
Certificate number: ________________________________
I have successfully completed twenty-four (24) hours of in-service/continuing education (CE) hours during my most
recent certification period (twelve (12) hours per year).
4. I have successfully completed forty-eight (48) hours of in-service/CE hours during my most recent certification period.
5.
Employer name Telephone number Last date worked
Address (number and street name or P.O. Box number)
City State ZIP code
6.
CNA APPLICANTS ONLY: I have not completed both renewal requirements listed above (Questions 4 and 5);
therefore, I wish to reactivate my CNA certificate by passing the competency evaluation (Testing).
(Please review Section C on the back of this application. Testing information will be sent to you.)
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 283C (06/11) This form is available on our website at: www.cdph.ca.gov
Male Female
( )
( )
I have provided nursing or nursing-related services in a facility to residents for compensation (under the supervision of
a licensed health professional) within my most recent certification period.
List current or most recent facility, agency, or organization.
CNA APPLICANTS ONLY: If you answered "No" to either question 4 or 5, please go to question 6.
REACTIVATION:
3.
HHA APPLICANTS ONLY:
ALL APPLICANTS:
CNA Renewal
HHA Renewal
No
Yes
No Yes
No Yes
No
Yes
Since your last certification period, have you been CONVICTED, of any crime, other than a minor 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.)
Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled,
cancelled, suspended, etc.) against you?
- If yes, indicate the type and number of license/certificate:
Yes No
NoYes
1.
2.
- If yes, list conviction:
Court of conviction: Date:
Print Form
CDPH 283C (06/11) This form is available on our website at: www.cdph.ca.gov
B.
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.)
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.
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.
ADDITIONAL INFORMATION
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.
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 have completed twenty-four (24) hours of in-service/CE hours (twelve (12) hours per twelve (12) months).
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.
*NAME AND ADDRESS CHANGES*
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