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Box 997416 Sacramento, CA 95899-7416  \nPhone: (916) 327-2445  \nSubmit application Online:  \n[cdph.ca.gov/Programs/CHCQ/LCP/Pages/](cdph.ca.gov/Programs/CHCQ/LCP/Pages/)[ ](cdph.ca.gov/Programs/CHCQ/LCP/Pages/)[Online-Submission-Page.aspx\\#](Online-Submission-Page.aspx#)  \nSection I (Required)  \nType of Request  \nCheck here if you are enrolling in a CHT training program (complete sections I -VIII)  \nCheck here if you are requesting RECONSIDERATION for a previously revoked/denied certificate (complete sections I, II, III, IV, V and VIII)  \n\n| Section II (Required) |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Last Name |  | First Name |  |  |  | MI | Sex\u003Cbr>Male Female |\n| Public Address (Required)– Subject to Public Records Act Request release* |  |  | City |  |  | State | \u003Cbr>Zip Code |\n| Confidential Address (Optional)- (For CDPH Use only. If left blank all departmental mail will be sent to the address above) |  |  | City |  |  | State | Zip Code |\n| Date ofBirth | Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN) ** If you use an invalid SSN, your application process may be delayed\u003Cbr>- - |  |  |  | Driver’s License or State ID Number Number  \u003Cbr>State   |  |  |\n| (mm/dd/yy) |  |  |  |  |  |  |  |\n| Phone Number *** |  |  |  | Email Address*** |  |  |  |\n\nCDPH 283 F (7/2024) This form is available on our website at: [cdph.ca.gov](cdph.ca.gov) Page 1 of 4  \nSection III (Required)  \nHas any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended, etc. ) against you?  \nYes No  \nType of License/Certificate:   License/Certificate Number:   Type of Action:    \nSection IV (Required)  \nDo you possess a High School Diploma or equivalency ( i.e. General Education Development GED, High  \nSchool equivalency, etc. ) ? Yes No  \nIf you answered yes, you must list the name and address where you successfully obtained your High School Diploma or equivalency. You must attach a copy of High School Diploma or GED to this application when applying for certification.  \nName City and Country Date/Year Diploma or Equivalency  \nwas obtained  \nSection V (Required)  \nYou must list the name and address of the approved CHT training program by CDPH where you successfully completed the training:  \nName City CHP Provider Number Completion Date (mm/dd/yy)  \nPrinted Name of Registered Nurse (RN) Trainer  \nSignature of RN Trainer  \nDate  \nYou must list the name and address of the provider where you successfully passed the test examination:  \n\n| Name of Test/Examination Provider | Phone Number | Pass Date (mm/dd/yy) |\n| --- | --- | --- |\n\nCDPH 283 F (7/2024) This form is available on our website at: [cdph.ca.gov](cdph.ca.gov) Page 2 of 4  \nSection VII (Required)  \nYou must list the name, city, phone number and hire date of the place you are currently employed:  \n\n| Name of Employer | City | Phone Number | Hire Date (mm/dd/yy) |\n| --- | --- | --- | --- |\n\nSection VIII (Required)  \nI 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 record keeping system to the fullest extent permitted by applicable law.  \nSignature of Applicant  \nCDPH 283 F (7/2024)  \nDate  \nThis form is available on our website at: [cdph.ca.gov](cdph.ca.gov) Page 3 of 4  ","cbCaidFJ15W4SsQZ","https://ap.wps.com/l/cbCaidFJ15W4SsQZ","pdf",362055,"English","# Section I (Required)\n## Type of Request\n# Section II (Required)\n## Applicant Information\n# Section III (Required)\n## Prior Licensing/Disciplinary Actions\n# Section IV (Required)\n## Education Requirement\n# Section V (Required)\n## Training and Test Completion\n# Section VII (Required)\n## Current Employment Details\n# Section VIII (Required)\n## Certification and Signature","[{\"question\":\"What request types can be selected in Section I of the CH T initial application?\",\"answer\":\"Applicants can choose enrollment in a CHT training program (completing Sections I–VIII) or request reconsideration for a previously revoked/denied certificate (completing Sections I, II, III, IV, V, and VIII).\"},{\"question\":\"What documentation is required for the education section?\",\"answer\":\"If the applicant has a high school diploma or equivalency (including GED), the applicant must list where it was obtained and attach a copy of the diploma or equivalency when applying for certification.\"},{\"question\":\"What must applicants certify and sign in Section VIII?\",\"answer\":\"Applicants certify under penalty of perjury that the information and supporting documents are true and correct, acknowledge that false or incomplete statements may lead to denial, and confirm that electronic signatures have the same legal validity as manual signatures.\"}]","Certified Hemodialysis Technician (CHT) - Initial Application | PDF",1790042594]