Homepage Fill Out Your Cdph Cna Form
Article Structure

The Certified Nurse Assistant (CNA) Initial Application form, known as the CDPH CNA form, plays a crucial role in the pathway to becoming a certified health aide in California. This comprehensive document not only collects necessary personal information, such as the applicant's name, contact details, and Social Security number, but also requires applicants to specify the type of request they are making—whether they are enrolling in a training program, seeking equivalency from other training, or applying for reciprocity from another state. Importantly, this form must be submitted without any processing fee, yet it underscores the necessity for accurate and complete responses, as an incomplete application will not be processed. The form has several sections that address various requirements, including criminal history disclosure and certification training details. Additionally, applicants are informed on crucial steps, such as the need for fingerprinting and providing documentation affirming their training. Ultimately, the CDPH CNA form serves as both a gateway and a safeguard, ensuring that those who seek to serve as nurse assistants have met the necessary standards before entering the workforce.

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: cna@cdph.ca.gov

 

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: cna@cdph.ca.gov

 

Form Characteristics

Fact Name Details
Governing Laws The form is governed by the California Health and Safety Code sections 1200 - 1797.8, among others.
Application Fee There is no fee to process the application. This helps ensure accessibility for all applicants.
Application Requirements Applicants must complete specified sections based on their request type, including training, equivalency, or reciprocity.
Privacy Regulations Under the Public Records Act, certain applicant information may be disclosed unless marked confidential.
Criminal Record Clearance Applicants must undergo fingerprinting via the Live Scan process to obtain a criminal record clearance for certification.
Application Submission Completed applications should be mailed or faxed to the California Department of Public Health (CDPH) Licensing and Certification Program.

Guidelines on Utilizing Cdph Cna

Completing the CDPH CNA form is a critical step for those seeking certification as a Certified Nurse Assistant in California. It is essential to follow the instructions carefully to ensure your application is processed smoothly. Incomplete applications may result in delays or rejection.

  1. Begin by selecting the type of request you are submitting. Check the appropriate box for enrolling in a CNA training program, having equivalent training, or requesting reciprocity from another state.
  2. Provide your personal information in Section II. Fill in your last name, first name, middle initial, sex, public address, confidential address (if applicable), date of birth, Social Security Number or Individual Taxpayer Identification Number, driver’s license or state ID information, email address, and phone number.
  3. Answer the questions in Section III regarding any past criminal convictions and any adverse actions taken against your health-related licenses. If applicable, provide details about convictions and licenses.
  4. If you are enrolling in a CNA training program, complete Section IV with the name and address of your training facility, along with the program ID number and training dates.
  5. In Section V, certify that the information provided is accurate by signing and dating the application.
  6. If you are a current student, ensure that a registered nurse responsible for your training completes Section VI as verification. This step includes their printed name, title, signature, and the date.
  7. Make a copy of your completed application for your records.
  8. Submit the application via mail or fax to the California Department of Public Health as stated at the top of the form. Ensure that you include all required documents mentioned in the instruction notes.

Pursuing certification takes diligence. Stay organized and keep track of your submission to address any follow-up actions or additional requirements that may arise.

What You Should Know About This Form

What is the purpose of the Cdph Cna form?

The Cdph Cna form serves as the initial application for individuals seeking certification as a Certified Nurse Assistant (CNA) in the State of California. This application facilitates the enrollment in CNA training programs, requests for equated training recognition, or reciprocity from other states. Completing this form is essential for potential CNAs to begin their certification process and ensure compliance with state regulations.

What information is required on the form?

Applicants must complete several sections of the form, including personal identification details such as name, date of birth, social security number, and contact information. Additionally, specifics regarding the type of request—whether for CNA training enrollment, equivalent training, or reciprocity—must be indicated. Applicants must also disclose information about any criminal convictions or disciplinary actions from health-related licensing authorities.

Is there a fee associated with submitting the application?

No fee is required to process the Cdph Cna application. All applicants can submit their forms free of charge. However, it is crucial that the application is complete and that all applicable questions are answered; otherwise, processing will not begin.

What are the requirements for criminal record clearance?

Upon enrolling in a CDPH-approved training program, applicants must undergo a fingerprinting process through Live Scan. All criminal convictions will be reviewed. If a conviction prohibits certification, the applicant will be notified. Certification cannot be granted until the criminal record is cleared.

How long does the CNA certification last before needing renewal?

The initial CNA certificate is valid for two birthdays, meaning it expires on the holder's birthday rather than on a calendar year basis. Renewal is required every two years. Applicants can renew their certification within two years after expiration, provided they meet specific prerequisites, including continued employment in nursing services and the completion of required training hours.

What happens if I need to change my address or name after certification?

Certificate holders must notify the California Department of Public Health within sixty days of any change of address. If a name change occurs, legal documentation must be submitted. Failure to report these changes can result in delays or complications with the certification status.

Common mistakes

Filling out the Cdph Cna form is a critical step for anyone looking to become a Certified Nurse Assistant in California. However, many applicants make mistakes that can delay their application process. One common error is not answering all the applicable questions. Leaving a question blank may cause the application to be rejected, resulting in time lost that could have been avoided.

Another frequent mistake involves inaccurately providing personal information. For instance, failing to include the correct Social Security Number (SSN) can lead to delays. Such errors may delay the criminal record clearance process, and applicants could be left waiting longer than necessary. Always ensure that the SSN matches what is on official documents.

Many applicants also overlook the requirement for a confidential address. If this address section is left blank, all mail will default to the public address provided. This can lead to sensitive information being sent to an address that may not be secure, compromising privacy.

The criminal history section is another area where mistakes occur. Some individuals might inadvertently omit past convictions, including minor infractions, believing they are not relevant. However, truthfulness is essential. Omitting such information can have serious repercussions, including potential disqualification from certification.

In addition, applicants sometimes fail to accurately fill out training details. When completing Section IV, indicating the correct California Training Program ID Number is vital. An incorrect number can lead to the training being unrecognized by the CDPH, causing unnecessary delays.

For applicants seeking reciprocity from another state, forgetting to provide proof of certification from the previous state is a common misstep. Without this documentation, the application may be incomplete and face rejection. Applicants must ensure they include a copy of their state-issued certificate to streamline the process.

Submitting the application without the required signature is another error that can halt progress. Section V clearly states that a signature is required to certify the information provided. Neglecting this can result in an outright denial of the application.

In some cases, applicants provide an email or phone number that is not accurate or outdated. Since this information is essential for communication regarding the application, ensure that it is current and accessible.

Finally, not double-checking the entire application before submission can lead to various mistakes, including typographical errors. A final review could catch these small yet impactful errors, ultimately saving time and ensuring a smoother application process.

To avoid these mistakes, it is crucial to take the time to read and re-read every section of the Cdph Cna form carefully. Attention to detail can make a significant difference in successfully obtaining certification in a timely manner.

Documents used along the form

The Certified Nurse Assistant (CNA) Initial Application (CDPH CNA form) is critical for individuals pursuing certification in California. Along with the CDPH CNA form, there are several other forms and documents that applicants may need to provide during the certification process. Understanding these supplementary forms is essential for a smooth application experience.

  • Request for Live Scan Services (BCIA 8016): This form is necessary for applicants to get fingerprinted as part of the criminal background check process. It must be submitted to the California Department of Public Health upon enrollment in a CNA training program.
  • Verification of Current Nurse Assistant Certification (CDPH 931): This document confirms the applicant's active certification status in another state. It is required for those seeking reciprocity to practice in California.
  • CDPH 283A: In-Service Training Documentation: This form is utilized when renewing a CNA certification. It verifies the completion of the required hours of in-service training and must include the instructor's signature.
  • Official Transcripts: For equivalency-trained nurse assistant applicants, official transcripts from nursing programs or military training can demonstrate eligibility for taking the Competency Evaluation. Sealed letters on official letterhead can also be submitted.
  • Proof of Work Documentation: Applicants may be required to submit paystubs or W-2 forms to show recent nursing work experience in a facility. This is crucial for those applying under equivalency or reciprocity conditions.

Collectively, these documents complement the CDPH CNA form and help streamline the certification process. Providing complete and accurate information in all forms will support applicants in achieving their goal of becoming Certified Nurse Assistants in California.

Similar forms

The Certified Nurse Assistant (CNA) Initial Application form, administered by the California Department of Public Health (CDPH), bears similarities to several other regulatory and licensing documents used in health care and professional fields. Below is a list of ten documents that share characteristics with the CDPH CNA form, highlighting how they are similar:

  • Nursing License Application: Like the CNA application, this document requires personal identification, educational history, and proof of training in nursing. Both forms aim to ensure that the applicant meets specific standards before licensure.
  • Licensed Vocational Nurse (LVN) Application: This application also asks for detailed personal information and criminal background disclosures. The LVN license is similar in purpose to the CNA certification, focusing on healthcare services delivery.
  • Home Health Aide Application: Akin to the CNA application, this document requires similar identification information and verification of training. Both licenses are aimed at individuals providing direct patient care.
  • Health Care Assistant Registration Form: This registration form parallels the CNA form in that it collects applicant data, training verification, and background checks, ensuring qualified individuals take on supportive caregiving roles.
  • Medication Aide Application: Similar to the CNA form, this application encompasses sections for personal information and training verification, focusing on individuals who will administer medications to patients.
  • Certified Nursing Assistant Renewal Application: This document closely mirrors the initial application in terms of required data, though it focuses on verifying ongoing compliance with training and experience requirements.
  • Physical Therapist Assistant Application: This form includes similar sections for personal identification, training, and aptitude assessments, ensuring applicants are well-prepared to support physical therapy services.
  • Occupational Therapy Assistant Application: Like the CNA form, this application asks for personal data, education, and experience details, focusing on individuals who provide supportive care in occupational therapy settings.
  • Certified Hemodialysis Technician Application: This application includes similar requirements for training and criminal background checks, aimed at ensuring individuals provide safe and effective dialysis care.
  • Emergency Medical Technician (EMT) Application: Similar to the CNA application, this form requires personal information, training credentials, and background checks to guarantee that applicants meet the necessary standards for emergency medical services.

Dos and Don'ts

Things to Do:

  • Complete all required sections of the Cdph Cna form.
  • Provide a valid Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN).
  • Check the appropriate box to indicate your type of request, whether for training, equivalency, or reciprocity.
  • Sign and date the application to certify that the information is accurate.

Things Not to Do:

  • Do not leave any applicable questions unanswered, as this will prevent processing.
  • Avoid using an invalid SSN, as this can delay your application process.
  • Do not forget to provide a confidential address if you are concerned about public records.
  • Do not attempt to submit your application without the necessary supporting documents, such as fingerprints for criminal record clearance.

Misconceptions

  • Misconception 1: There is a fee to process the application.
  • Many believe that applying for a Certified Nurse Assistant (CNA) position comes with application fees. However, the CDPH clearly states that there is no fee to process this application.

  • Misconception 2: All questions on the application are optional.
  • Some applicants think they can skip questions on the form. This is incorrect. Your application will not be processed if all applicable questions are not answered.

  • Misconception 3: Providing a Social Security Number is optional.
  • Individuals often assume that submitting a Social Security Number (SSN) is voluntary. In fact, it is mandatory for the application process. Failure to provide it can delay or reject your application.

  • Misconception 4: You don’t need training to apply if you have a foreign certification.
  • Some believe that possessing a foreign nursing certification is enough. However, applicants seeking certification based on foreign training must still meet all California state requirements and prove eligibility for the Competency Evaluation.

  • Misconception 5: Applicants are not required to disclose minor traffic violations.
  • While it's true that you don’t need to disclose minor traffic offenses, applicants should be aware that any serious convictions must be listed. Failing to do so could hinder your application.

  • Misconception 6: You can take the competency evaluation immediately after training.
  • Some applicants think they can take the competency test right after completing training. This is not always the case. You must first receive a criminal record clearance before being eligible to take the evaluation.

  • Misconception 7: Renewing your CNA certificate is automatic.
  • Many individuals believe that their CNA certification will renew itself automatically. In reality, certificates must be renewed every two years, and specific requirements must be met. Failing to renew on time can lead to a delay in status or loss of certification.

Key takeaways

When applying to become a Certified Nurse Assistant (CNA) in California, understanding how to properly fill out the CDPH CNA form is crucial. Here are some key takeaways:

  • The application must be *completely filled out*. Leaving questions unanswered will lead to processing delays.
  • There is *no fee to process* this application. This means you won't incur any costs just for applying.
  • Be prepared to complete all five sections of the application, depending on your situation, whether you're enrolling in a training program, have equivalent training, or are requesting reciprocity from another state.
  • Privacy is important. Your public address will be subject to release under the Public Records Act, but your confidential address will be kept private.
  • Applicants must undergo fingerprinting through the Live Scan process upon enrollment in a CDPH-approved training program. This is necessary for a criminal record clearance.
  • Documentation is key. Make sure to submit any required transcripts or proof of training if applying under equivalency or reciprocity.
  • Keep an eye on your certification status. The initial CNA certificate will expire on your birthday every two years and must be renewed accordingly to maintain its validity.