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Certified Hemodialysis Technician (CHT) Initial …

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Text of Certified Hemodialysis Technician (CHT) Initial …

________________________________________ _________ ________________________________ State of California- Health and Human Services Agency California Department of Public Health (CDPH) Licensing and Certification Program (L&C) Aide and Technician Certification Section (ATCS) MS 3301, Box 997416 Sacramento, CA 95899-7416 PHONE: (916) 327-2445 FAX: (916) 552-8785 EMAIL: CERTIFIED HEMODIALYSIS TECHNICIAN (CHT) INITIAL APPLICATION (See instructions on the reverse) Last Name First Name MI Sex Male Female Address (Number and Street or Box Number) City State Zip Code Date of Birth *Social Security Number (SSN) ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Driver s License Number Number: _______________________ State: _______________________ Telephone Number 1) Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended, etc.) against you? -If yes, indicate the type and number of license/certificate:____________________ ________________ Yes No 2) EDUCATION Do you possess a High School Diploma or equivalency ( General Education Development (GED), High School equivalency, etc.)? You must list the name and address where you successfully obtained your High School Diploma or equivalency: Yes No Name Telephone Number Date/Year Diploma or Equivalency was Obtained Address (Number and Street or Box Number) City State Zip Code Country 3) TRAINING You must list the name and address of the CHT training program where you successfully completed training: Name Telephone Number Provider Number Completion Date Address (Number and Street or Box Number) City State Zip Code Country Printed Name of Registered Nurse (RN) Trainer Signature of RN Trainer Date 4) TEST / EXAMINATION You must list the name and address of the provider where you successfully passed the test / examination: Name of Test / Examination Provider Telephone Number Provider Number Pass Date Address (Number and Street or Box Number) City State Zip Code Country Printed Name of Testing / Examination Proctor Signature of Testing / Examination Proctor Date I certify, under penalty of perjury under the laws of the State of California, that the foregoing is true and correct. Signature of Applicant Date CDPH 283 F (07/12) This form is available on our website at: Page 1 of 2 CERTIFIED HEMODIALYSIS TECHNICIAN (CHT) GENERAL INFORMATION A CHT may not perform any duties that require a professional medical or nursing license. A) Requirements for Initial Certification (must meet all three (3) requirements) 1) Education a)Have a High School Diploma or equivalency (GED or High School equivalency). 2) Training a)Have successfully completed a training program that is approved by the medical director and governing body of a Hemodialysis clinic/unit, under the direction of a RN. The training program must be approved by CDPH prior to implementation; OR b)Have successfully completed a community or corporate-based training program, or a training program offered by an educational institution approved by CDPH. In addition, you must have passed a written examination offered by a Hemodialysis clinic/unit, or a community or corporate-based training program that meets California law and a skills checklist observed by an RN. 3) Test / Examination a)Have successfully passed a standardized test that is approved by CDPH; OR b)Have successfully passed an examination offered by a national commercially available certification program for CHTs, which is approved for this purpose by CMS. B) Requirements for Renewal 1) Must submit a completed Renewal Application (CDPH 283 G); AND 2) Must obtain thirty (30) hours of In-Service Training/Continuing Education Units (CEUs) in dialysis care or general health care and submit proof of the completed hours with the CDPH 283 G. Applicants must submit copies of their certificates of completion with the CDPH 283 G to verify the In-Service Training/CEU requirement has been met. No other documentation will be accepted for the In-Service Training/CEU verification purpose. The submission of the completed thirty (30) hours of In-Service Training/CEUs is required, per Business and Professions Code, Division 2, Chapter 3, Article , Section (b). C) In-Service Training/CEUs 1) CHTs may obtain In-Service Training/CEUs from the following sources: a)Health-related courses offered by accredited postsecondary institutions (colleges and adult education facilities) b)Health-related courses offered by continuing education providers approved by the California Board of Registered Nursing c)Health-related courses offered by recognized health associations if the department determines the courses to be acceptable d)Health-related employer-sponsored In-Service Training/CEU programs 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 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 F (07/12) This form is available on our website at: Page 2 of 2

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