Certified Nurse Assistant (CNA) and/or Home Health Aide (HHA) Renewal Application

Certified Nurse Assistant (CNA) AND/OR Home Health Aide (HHA) Renewal Application
Your Application will not be processed if all applicable questions are not answered!
Section I (Type of Request)

CNA Renewal (complete sections I, II, III, ,9V, and VII)HHA Renewal (complete sections I, II, III, IV, and VII)
CNA Reactivation (complete sections I, II, III, V, VI, and VII)
CNA Certificate number
HHA Certificate number
CNA Reactivation : Certificate number
Section II (Required)
Last Name
MI
Public Address (Required) Subject to Public Records Act .

Confidential Address 2SWLRQDO- For CDPH Use only. If left City

Street Address Line 2

CityState

Zip Code
City
Residential Address (Optional)..If blank, all departmental mail will be sent to the address above
Adress
City

blank all departmental mail will be sent to the address above

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
Date
SSN OR Individual Taxpayer Identification Number (ITIN)
Phone Number
By checking this box, you agree to receive text messages from the

California Department of Public Health (CDPH) for reminders and notifications regarding your application and/or certification.
Email Address 1
Email Address 2
Section III (Required)

1)Since your last renewal, have you been CONVICTED, at any time, of any crime, other than a minor traffic violation? (You need not disclose any marijuana-related offenses specified in the marijuanareform legislation and codified at the Health and Safety Code, Sections 11361.5 and 11361.7
YesNo
If yes, list conviction
Court of conviction
Date

MonthDayYear
Date
2. Since your last renewal, has any health-related licensing, certification or disciplinary authority taken adverse action revoked, annulled, cancelled, suspended, etc against you?

YesNo
Type of License/Certificate:
License/Certificate Number:
Type of Action
Section IV - HHA Applicants Only

if applying for dual certification, YOU MUST COMPLETE QUESTIONS 3 and 4
3. I have successfully completed and included documentation of 24 hours of In-Service Training/CEUs during my most recent certification period. Twelve 12 of the 24 hours were completed in each year of my two 2 year certification period (HHA and may not be completed online CEUs)

YesNo
CNA Applicants Only
4. I have successfully completed and included documentation of 48 hours of In-Service Training/CEUs during my most recent certification period. Twelve 12 of the 48 hours were completed in each year of my two 2 year certification period (CNAs may complete maximum 24 hours online CEUs)

YesNo
SECTION V. (Required for CNA; If applicable for HHA In-service hours verification). Have you worked as a CNA/HHA in a facility for compensation (under the supervision of a licensed health professional) within your two (2) year certification period? If you have, check the “Yes” box 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

No
Yes
Name of Employer 1 or Facility Name
Employment Dates (mm/dd/yy) From:

MonthDayYear
Date
To

MonthDayYear
Date
Are You Currently Working?
Employer's Mailing Address (Number and Street City Or P.O. Box Number)
City
State
Zip Code
Name of Employer 2 or Facility Name.
Mailing Address (Number and Street Or P.O. Box Number)
Address

City

Street Address Line 2

CityState

Zip Code
Employment Dates . From

MonthDayYear
Date
To

MonthDayYear
Date
Currently

Working
Telephone Number
Section VI. CNA applicants who do not meet the renewal requirements only
6. Reactivation: I have not completed one (1) or both of the renewal requirements listed above in question four (4) and question five (5) and wish to reactivate my CNA certificate by re-taking both the skills and written portion of the Competency Evaluation (exam).If approved, a Competency Evaluation approval letter will be sent to you, along with information to schedule the examination. NOT APPLICABLE?

YesNo
I certify under penalty and perjury under the applicable state and federal laws that the information contained in this application and supporting documents, is true and correct. I further understand that any false, incomplete, or incorrect statements may result in denial of this application.

I acknowledge that signing this document through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based recordkeeping system to the fullest extent permitted by applicable law.
Signature of Applicant

Clear
Date Signed

MonthDayYear
Date
CERTIFCATION LOG

CERTIFICATION YEAR 1. First Year of CEUs and In-Service training
First year of my certification period:From

MonthDayYear
Date
To

MonthDayYear
Date
Printed Name of CNA/HHA (Required):
Social Security Number (Required):
Certification Number
Signature of Applicant (Required)

Clear
Date Signed

MonthDayYear
Date
Title of training / Course 1.
Was the Training Online?

Check to confirm
Agency Name / Approved Provider Name and NAC no.
Date of Attendance

MonthDayYear
Date
Hours Obtained
Title of training / Course 2.
Was the Training Online?

Check to confirm
Agency Name / Approved Provider Name and NAC no. (Course 2)
Date of Attendance Course 2.

MonthDayYear
Date
Hours Obtained (Course 2)
Total Combined Hours For Certification Year 1.
Second Year of my Certification period:

Year 2 of CEUs and In-Service training
From

MonthDayYear
Date
To

MonthDayYear
Date
Printed Name of CNA/HHA (Required)
SSN (Required)
Certification Number (Second Year Certification Period)
Signature of Applicant

Clear
Date Signed (Required)

MonthDayYear
Date
Was the First Training Online?

Check to confirm
Title of Training/course (Course 1)
Agency Name / Approved Provider Name and NAC no. (Course 1)
Date of Attendance Course 1. (Required)

MonthDayYear
Date
Hours Obtained Course 1
Title of Training/course (Course 2)
Was the Second Training Online?

Check to confirm
Agency Name / Approved Provider Name and NAC no. (Course 2)
Date of Attendance Course 2. (Required)

MonthDayYear
Date
Hours Obtained Course 2
Title of Training/course (Course 3)
Was the Third Training Online?

Check to confirm
Agency Name / Approved Provider Name and NAC no. (Course 3)
Hours Obtained Course 3
Date of Attendance Course 3. (Required)

MonthDayYear
Date
Second Year CEUs. Total Combined Hours of Training
Should be Empty:

Your Application will not be processed if all applicable questions are not answered!

Section II (Required)

Section IV - HHA Applicants Only

CNA Applicants Only

Section VI. CNA applicants who do not meet the renewal requirements only

CERTIFCATION LOG

Second Year of my Certification period: