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The form includes required disclosures about convictions and adverse licensing actions, and requires completion of specific training/continuing education hours depending on CNA or HHA eligibility. CNA and HHA applicants may also provide facility employment history, or request reactivation by retaking required competency components. 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CNA applicants attest to completing and including documentation of forty-eight (48) hours total, with twelve (12) hours in each year, noting CNA may complete a maximum of twenty-four online CEUs.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},306323,1791375543,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},962084925502,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","State of California-Health and Human Services Agency Mail or submit application Online:  \nCalifornia Department of Public Health (CDPH) Healthcare Workforce Branch (HWB) MS 3301, P.O. Box 997416  \nSacramento, 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#)  \nCertified Nurse Assistant (CNA) and/or Home Health Aide (HHA) Renewal Application  \n(See instructions on the reverse)  \nYour application will not be processed if all applicable questions are not answered.  \nSection I (Required)  \nType of Request  \n CNA Renewal (complete sections I, II, III, IV, V, and VII) Certificate number:  \n____________  \n HHA Renewal (complete sections I, II, III, IV, and VII) Certificate number:   CNA Reactivation (complete sections I, II, III, V, VI, and VII) Certificate number:   \n\n| Section II (Required) |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Last Name |  | First Name |  |  |  | MI |\n| Public Address (Required)– Subject to Public Records Act Request release * |  |  | City |  | State | Zip Code\u003Cbr>|\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\u003Cbr>(mm/dd/yy) | Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN)-If you use an invalid SSN, your application process may be delayed **\u003Cbr>      -     -         |  |  |  |  |  |\n| Phone Number *** |  |  |  | Email Address*** |  |  |\n\nCDPH 283 C (7/2024) This form is available on our website at: [cdph.ca.gov](cdph.ca.gov Page 1 of 5)[ Page 1 of 5](cdph.ca.gov Page 1 of 5)  \n Section III (Required)   \n1) 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 marijuana reform legislation and codified at the Health and Safety Code, Sections 11361.5 and 11361.7) .  \n- ☐ Yes ☐ No  \n- If yes, list conviction:    \n- Court of conviction:   Date:    \n2) Since your last renewal, 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:    \n-Type of Action:    \nSection IV– If applying for dual certification you must complete questions 3 and 4  \nHHA Applicants Only:  \n3) I have successfully completed and included documentation of twenty-four (24) hours of In-Service Training/Continuing Education Units (CEUs) during my most recent certification period. Twelve (12) of the twenty-four (24) hours were completed in each year of my two (2) year certification period (HHAs may not complete online CEUs) .  \n☐ Yes ☐ No  \nCNA Applicants Only:  \n4) I have successfully completed and included documentation of forty-eight (48) hours of In-Service Training/CEUs during my most recent certification period. Twelve (12) of the forty-eight (48) hours were completed in each year of my two (2) year certification period (CNAs may complete a maximum of twenty-four online CEUs)  \n☐ Yes ☐ No  \nSection V (Required for CNA; if applicable for HHA in-service hours verification  \n5) 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 and provide the facility information below, as well as list the dates of employment. All places of employment during the most recent certification period must be listed on the application. Please use a blank sheet of paper if you had more than two employers and 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 t","cbCaibZCsUHjcIEk","https://ap.wps.com/l/cbCaibZCsUHjcIEk","pdf",689263,"English","# Section I (Required)\n## Type of Request\n## Certificate number\n# Section II (Required)\n## Personal information and contact details\n# Section III (Required)\n## Convictions disclosure\n## Adverse action disclosure\n# Section IV (Dual certification, if applicable)\n## HHA in-service training/CEUs\n## CNA in-service training/CEUs\n# Section V (Required for CNA; if applicable for HHA)\n## Employment verification\n# Section VI (If applicable)\n## Reactivation request\n# Section VII (Required)\n## Certification and signature","[{\"question\":\"What information must be provided in Section I for CNA or HHA renewal?\",\"answer\":\"Section I requires the applicant to select the type of request (CNA Renewal, HHA Renewal, or CNA Reactivation) and provide the applicable certificate number, while completing the listed required sections.\"},{\"question\":\"What disclosures are required in Section III?\",\"answer\":\"Section III requires answering whether the applicant has been convicted of any crime since the last renewal (other than minor traffic violations) and whether any health-related licensing, certification, or disciplinary authority has taken adverse action since the last renewal.\"},{\"question\":\"How does the form distinguish CNA and HHA renewal training requirements?\",\"answer\":\"HHA applicants attest to completing and including documentation of twenty-four (24) hours of In-Service Training/CEUs (with twelve (12) hours in each year of a two-year period). CNA applicants attest to completing and including documentation of forty-eight (48) hours total, with twelve (12) hours in each year, noting CNA may complete a maximum of twenty-four online CEUs.\"}]","Certified Nurse Assistant (CNA) and/or Home Health Aide (HHA) Renewal Application - CDPH 283 C | PDF",1789835393]