State of California- Health and Human Services Agency MAIL OR FAX APPLICATION TO:

California Department of Public Health (CDPH)

Licensing and Certification Division (L&C)
Healthcare Workforce Branch (HWB)
MS 3301, P.O. Box 997416
Sacramento, CA 95899-7416
PHONE: (916) 327-2445 FAX: (916) 552-8785

CERTIFIED NURSE ASSISTANT (CNA)

EQUIVALENCY/RECIPROCITY APPLICATION
(See instructions on the reverse)
SECTION I (REQUIRED)
TYPE OF REQUEST
Check here if you have EQUIVALENT TRAINING (complete sections I, II, III, IV and VI)
Check here if you are requesting RECIPROCITY FROM ANOTHER STATE
(complete sections I, II, III, V and VI)

SECTION II (REQUIRED)
Last Name First Name MI Sex
Male
Female
Public Address (Required) – Subject to Public Records Act City State Zip Code
Request release*

Confidential Address (Required)- (For CDPH Use only. If left City State Zip Code
blank all departmental mail will be sent to the address above)

Date of Birth Social Security Number (SSN) or Individual Driver’s License or State ID Number

Taxpayer Identification Number (ITIN) Number

___ ___ ___ - ___ ___ - ___ ___ ___ ___
**If you use an invalid SSN, your application process State
(mm/dd/yy) may be delayed

Phone Number *** Email Address***

☐ 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 year.
Message and data rates may apply. By checking this box, you
agree to the Terms and Conditions and Privacy Policy.
Reply “STOP” to opt-out, and “HELP” for help.

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SECTION III (REQUIRED)
1) 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).
☐ Yes ☐ No
- If yes, list conviction: ________________________
- Court of conviction: _________________________ Date: ________________

2) Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked,
annulled, cancelled, suspended, etc.) against you?
☐ Yes ☐ No
- Type of License/Certificate: _________________________________
- License/Certificate Number: _________________________________
- Type of Action: __________________________________

SECTION IV EQUIVALENCY APPLICANTS (* are required fields)

*Type of Equivalent training received: *Name of School/Military Branch:
__________________________
*Date Fundamentals of Nursing completed:
______________ (mm/dd/yy)
*Did you obtain a passing score for
Name of Employer (if applicable): Fundamentals of Nursing?
_____________________________
Yes No
Last Date worked (if applicable):
_____________________________

SECTION V RECIPROCITY APPLICANTS (* are required fields)

*State transferring from: * CNA Certificate Number:

*Certificate Issue Date: *CNA Certificate Expiration Date:

Name of Employer: Last date worked (if applicable):

SECTION VI (REQUIRED)
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 record keeping system to the fullest extent permitted by applicable law.
________________________________ _____________________
Signature of Applicant Date

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 CERTIFIED NURSE ASSISTANT (CNA)
EQUIVALENCY/RECIPROCITY APPLICATION
A) EQUIVALENCY - TRAINED NURSE ASSISTANT APPLICANTS (complete sections I, II, III,
and V)
1) If the applicant is presently enrolled in (or completed) a Registered Nurse, Licensed Vocational Nurse, or
Licensed Psychiatric Technician program, or has received medical training in military services, or has received
the above license(s) from a foreign country or U.S. state, the applicant may not have to take further training
and may qualify to take the Competency Evaluation. If approved, the applicant will be sent information
regarding the Competency Evaluation. Please submit the following to HWB:
a) This completed Initial Application (CDPH 283 B).
b) An official, sealed transcript of training (students may substitute the transcript with a sealed letter on
official school letterhead, listing equivalent training and the completion of at least the "Fundamentals
of Nursing" course). The letter must include the completion date(s) of the training/courses and
hours/units completed. If discharged from the military, a copy of the DD-214 can substitute for an
official transcript. If seeking certification with the use of a foreign transcript, a copy of the foreign
transcript may be acceptable; and
c) Proof of work (paystub or W2) showing the applicant has provided nursing or nursing-related services
in a facility to residents for compensation within the last two (2) years (not required for current nursing
students or if the college degree was obtained within the last two (2) years); and
d) A copy of the completed Request for Live Scan Services (BCIA 8016) form. Applicants who are unable to
obtain electronic prints may complete the fingerprint card (FD-258) and submit two copies to the
department. Fingerprint cards (FD-258) must be accompanied by a $32.00 check or money order made
payable to “The Department of Justice”
B) RECIPROCITY APPLICANTS (complete sections I, II, III, and V)
1) If the CNA certification is active and in good standing on another state's registry, the applicant may qualify
for certification in the State of California without taking CNA training or the Competency Evaluation. Please
submit the following to HWB:
a) This completed Initial Application (CDPH 283 B).
b) A copy of the state-issued certificate; and
c) Proof of work (paystub or W2) showing the CNA has provided nursing or nursing-related services in a
facility to residents for compensation within the last two (2) years (not required for those who received
their initial certification from another state within the last two (2) years); and
d) A copy of the completed Request for Live Scan Services (BCIA 8016) form completed in California.
Applicants residing out of state may complete the fingerprint card (FD-258) and submit two copies to
the department. Fingerprint cards (FD-258) must be accompanied by a $32.00 check or money order
made payable to “The Department of Justice”; and
e) A completed Verification of Current Nurse Assistant Certification (CDPH 931) form, which must be
completed by the applicant and submitted by the endorsing state agency.

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 C) CRIMINAL RECORD CLEARANCE
1)All CNA applicants must undergo a criminal record review. For more information, please visit us at
www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/CriminalRecordReview.aspx.
D) CNA RENEWAL INFORMATION
1)The initial CNA certificate is issued for two birthdays, not two calendar years, and will expire on your
birthday. Each year of the certification period will be from one birthday to the following birthday. Any
additional time from the effective date until the first birthday will be counted towards the first year of the
certification period. CNA certificates must be renewed every two (2) years. You may renew your certificate any
time within two (2) years after the expiration date For more information, please visit us at
https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/CNA.aspx
E) NAME AND ADDRESS CHANGES
1)Certificate holders shall notify CDPH within sixty (60) days of any change of address. If requesting a name
change, submit legal verification of the change (marriage certificate, divorce decree, or court documents).
Failure to report a name or address change may result in the delay or loss of your certification.

Aforementioned requirements are based on Health and Safety Code commencing with §1337 through 1338.5,
1725 through 1742 and Code of Federal Regulations Title 42, Chapter IV, commencing with §483.13 and
California Code of Regulations, Title 22, commencing with §71801.

INFORMATION COLLECTION AND ACCESS-PRIVACY STATEMENT

*Pursuant to a court order, the California Department of Public Health will be required to release the address of
record for certified nurse assistants, home health aides, certified hemodialysis technicians, and licensed nursing
home administrators in response to a Public Records Act (PRA) request. (Government Code starting at section 6250.)
Court Order: Service Employees International Union-United Healthcare Workers v. California Department of Public
Health, Sacramento County Superior Court, February 21, 2018, No. 34-2017-80002636.**If you use an invalid SSN,
your application process may be delayed ***Providing your telephone number and email address is for the
California Department of Public Health's internal use only for contacting applicants. This information will not be
released to the public nor will it be displayed online

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