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Box 997416 Sacramento, CA 95899-7416  \nPHONE: (916) 327-2445 FAX: (916) 552-8785  \nCERTIFIED NURSE ASSISTANT (CNA) INITIAL APPLICATION  \n(See instructions on the reverse)  \n\n| SECTION I (REQUIRED) |  |\n| --- | --- |\n| TYPE OF REQUEST |  |\n| | Check here if you are enrolling in a CNA training program (complete sections I, II, III, IV, and V) Check here if you are requesting RECONSIDERATION for a previously revoked/denied certificate |\n| (complete sections I, II, III and V) |  |\n\nSECTION II (REQUIRED)  \n\n| Last Name |  | First Name |  |  |  | MI | Sex Male\u003Cbr>Female |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Public Address (Required)–Subject to Public Records Act Request release* |  |  | City |  |  | State | Zip Code\u003Cbr>|\n| Confidential Address (Required) - (For CDPH Use only. If left blank all departmental mail will be sent to the address above) |  |  | City |  |  | State | Zip Code |\n| Date of Birth\u003Cbr>(mm/dd/yy) | Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN)\u003Cbr>- -\u003Cbr>\u003Cbr>\u003Cbr>**If you use an invalid SSN, your application process may be delayed |  |  |  | Driver’s License /State ID Number Number:  \u003Cbr>State:   |  |  |\n| Phone Number ***\u003Cbr>☐ 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. You may receive up to 5 messages per month. Message and data rates may apply. By checking this box, you agree to the Terms and Conditions and Privacy Policy.\u003Cbr>Reply “STOP” to opt-out, and “HELP” for help. |  |  |  | Email Address*** |  |  |  |\n\nCDPH 283 B (01/22) This form is available on our website at: [www.cdph.ca.gov](www.cdph.ca.gov) Page 1 of 3  \nSECTION III (REQUIRED)  \n1) 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 marijuana reform legislation and codified at the Health and Safety Code, Sections 11361.5 and 11361. 7) .  \n Yes  \n No  \nIf yes, list conviction:    \nCourt of conviction:   Date:    \n2) Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended, etc.) against you?  \n Yes  No  \nType of License/Certificate:    \nLicense/Certificate Number:    \nType of Action:    \n\n|  SECTION IV (IF APPLICABLE) |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Name of school or facility where you received/will receive the CNA training |  |  |  | Telephone Number |  |  |\n| Mailing Address (Number Street or P.O Box number | City |  | State |  |  | Zip Code |\n| California Training Program ID Number for CNA (Required) CNA:   |  | Beginning Date of Training\u003Cbr>(mm/dd/yy) |  |  | End Date of Training\u003Cbr>(mm/dd/yy) |  |\n\nSECTION V (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 Date  \n\n| SECTION VI: TO BE COMPLETED BY THE REGISTERED NURSE RESPONSIBLE FOR THE GENERAL SUPERVISION OF THE TRAINING PROGRAM |  |\n| --- | --- |\n| I certify that this individual has successfully completed state and federal nurse assistant training requirements and is eligible to take the Competency Evaluation (only applies to students tha","cbCaiatQkHhypwRY","https://ap.wps.com/l/cbCaiatQkHhypwRY","pdf",334948,"English","# SECTION I (REQUIRED)\n## TYPE OF REQUEST\n# SECTION II (REQUIRED)\n## Applicant Information\n# SECTION III (REQUIRED)\n## Criminal and Licensing Background Questions\n# SECTION IV (IF APPLICABLE)\n## CNA Training Program Details\n# SECTION V (REQUIRED)\n## Applicant Certification and Signature\n# SECTION VI\n## Registered Nurse Completion (General Supervision)","[{\"question\":\"What options are available under the “Type of Request” section?\",\"answer\":\"Applicants select enrollment in a CNA training program or request reconsideration for a previously revoked/denied certificate. The form indicates which sections must be completed for each request type.\"},{\"question\":\"What background information must applicants provide in Section III?\",\"answer\":\"Applicants must disclose any convictions (except minor traffic violations) and whether any health-related licensing/certification authority has taken adverse action against them. If “Yes,” required details such as court and dates, or type of action, must be listed.\"},{\"question\":\"What information is required in Section IV for applicable applicants?\",\"answer\":\"Section IV requests the name and address of the school or facility where CNA training was received or will be received, along with the California Training Program ID number and the training beginning and end dates.\"},{\"question\":\"What does Section VI require?\",\"answer\":\"Section VI must be completed by the registered nurse responsible for general supervision, certifying the individual successfully completed state and federal nurse assistant training requirements and is eligible for the competency evaluation (as applicable).\"}]","California Department of Public Health - CERTIFIED NURSE ASSISTANT (CNA) INITIAL APPLICATION - CDPH 283 B | PDF",1789288605]