CNA Application Form

Initial Enrollment Performance Convictions Payment

Initial Application

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

SECTION I:

SECTION II: Applicant Information

Driver’s License or State ID Number:

SECTION III: Legal History

SECTION IV (If Applicable)

SECTION V: (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.

SECTION VI: TO BE COMPLETED BY THE REGISTERED NURSE RESPONSIBLE FOR THE GENERAL SUPERVISION OF THE TRAINING PROGRAM

FOR VENDOR USE ONLY

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 that have recently completed a CNA Training Program in CA.

CERTIFED NURSE ASSISTANT (CNA) INITIAL APPLICATION INFORMATION

A) CNA APPLICANTS (complete sections I, II, III, IV, and V)

1) The applicant must submit the following to HWB upon enrollment in the program and before patient contact:
a) This completed Initial Application (CDPH 283 B); and
b) 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) 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.

C) 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

D) 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.

E) RECONSIDERATION

1)If the applicant’s CNA certificate was revoked or denied by the CDPH, after review of this application, the CDPH will reach out to the applicant for additional information/documentation as needed.
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

Enrollment Application

INTERNATIONAL SCHOOL OF NURSING

ENROLLMENT AGREEMENT

Nursing Assistant

SCHOOL NAME: International School of Nursing

ADDRESS: 1330 Springs Road, Vallejo, CA 94591 Tel. (707) 557-7173

Address where instruction will be provided: International School of Nursing, 1330 Springs Road, Vallejo, CA 94591

Address of Clinical Sites: Springs Road Healthcare, 1527 Springs Road, Vallejo, CA 94591 Tel. (707) 643-2793

B. Any questions a student may have regarding this enrollment agreement that have not been satisfactorily answered by the institution may be directed to Bureau for Private Postsecondary Education at 1747 N. Market Blvd. Ste. 225 Sacramento, CA 95834, P.O. Box 980818 West Sacramento, CA 95798-0818 Website: www.bppe.ca.gov, telephone number (888) 370-7589, or by fax (916) 263-1897, (916) 574-8900 or by fax (916) 263-1897.
A student or any member of the public may file a complaint about this institution with the Bureau for Private Postsecondary Education by calling (888) 370-7589 toll-free or by completing a complaint form, which can be obtained from bureau’s internet website www.bppe.ca.gov.

C. This agreement is a legally binding instrument when signed by the student and accepted by the school. Your signature on this agreement acknowledges that you have been given reasonable time to read and understand it and that you have been given: (a) a written statement of the refund policy including examples of how it applies and; (b) a catalog including a description of the course of educational service including all material facts concerning the school and the program or course of instruction which are likely to affect your decision to enroll. Immediately upon signing this agreement, you will be given a copy of it to retain.

D. If English is not the student's primary language, and the student is unable to understand the terms and conditions of the enrollment agreement, the student shall have the right to obtain a clear explanation of the terms and conditions and all cancellation and refund policies in his or her primary language. The institution does not provide English as a Second Language instruction.

E. This enrollment agreement is for the course: NURSE ASSISTANT TRAINING COURSE, 60 of hours Theory, 100 hours Clinical, a total of 160 hours are required to complete the course educational service.

F. The period covered by this enrollment agreement:

G. STUDENT'S RIGHT TO CANCEL

The student has the right to cancel his or her enrollment agreement...

H. DATE TO CANCEL

I. REFUND INFORMATION

The student has the right to cancel the enrollment agreement and obtain a refund of charges paid...

J. DATE OF REFUND

K. FINANCIAL AID FUNDS

If the student obtains a loan to pay for the educational program...

L. FEES AND CHARGES

  • Tuition: $1,300.00
  • Registration (non-refundable): $195.00
  • Book (non-refundable after cancel period): $50.00
  • Livescan (non-refundable after cancel period): $55.00
  • Uniform (non-refundable after cancel period): $30.00
  • STRF fee (non-refundable): $0.00

THE TOTAL CHARGES FOR CURRENT PERIOD OF ATTENDANCE IS $1,630.00

ESTIMATED TOTAL CHARGES OF THE ENTIRE EDUCATIONAL PROGRAM IS $1,630.00

TOTAL CHARGES THE STUDENT IS OBLIGATED TO PAY UPON ENROLLMENT IS $195.00

M. Prior to signing this enrollment agreement, you must be given a catalog or brochure...

N. A student shall enroll solely by means of executing an enrollment agreement...

O. To the best of my knowledge, I declare that the information submitted is true and correct.

P. NOTICE CONCERNING TRANSFERABILITY OF CREDITS AND CREDENTIALS EARNED AT OUR INSTITUTION

The transferability of credits you earn at International School of Nursing is at the complete discretion of an institution to which you may seek to transfer. Acceptance of the certificate you earn in Nursing Assistant Training Program is also at the complete discretion of the institution to which you may seek to transfer. If the certificate that you earn at this institution is not accepted at the institution to which you seek to transfer, you may be required to repeat some or all of your coursework at that institution. For this reason you should make certain that your attendance at this institution will meet your educational goals. This may include contacting an institution to which you may seek to transfer after attending International School of Nursing to determine if your certificate will transfer.

Q. International School of Nursing does not offer a distance educational program.

R. The State of California established the Student Tuition Recovery Fund (STRF) to relieve or mitigate economic loss suffered by a student in an educational program at a qualifying institution, who is or was a California resident while enrolled, or was enrolled in a residency program, if the student enrolled in the institution, prepaid tuition, and suffered an economic loss. Unless relieved of the obligation to do so, you must pay the state-imposed assessment for the STRF, or it must be paid on your behalf, if you are a student in an educational program, who is a California resident, or are enrolled in a residency program, and prepay all or part of your tuition. You are not eligible for protection from the STRF and you are not required to pay the STRF assessment, if you are not a California resident, or are not enrolled in a residency program.”
To be eligible for STRF, you must be a California resident or are enrolled in a residency program, prepaid tuition, paid or deemed to have paid the STRF assessment, and suffered an economic loss as a result of any of the following:
1. The institution, a location of the institution, or an educational program offered by the institution was closed or discontinued, and you did not choose to participate in a teach-out plan approved by the Bureau or did not complete a chosen teach-out plan approved by the Bureau.
2. You were enrolled at an institution or a location of the institution within the 120 day period before the closure of the institution or location of the institution, or were enrolled in an educational program within the 120 day period before the program was discontinued.
3. You were enrolled at an institution or a location of the institution more than 120 days before the closure of the institution or location of the institution, in an educational program offered by the institution as to which the Bureau determined there was a significant decline in the quality or value of the program more than 120 days before closure.
4. The institution has been ordered to pay a refund by the Bureau but has failed to do so.
5. The institution has failed to pay or reimburse loan proceeds under a federal student loan program as required by law, or has failed to pay or reimburse proceeds received by the institution in excess of tuition and other costs.
6. You have been awarded restitution, a refund, or other monetary award by an arbitrator or court, based on a violation of this chapter by an institution or representative of an institution, but have been unable to collect the award from the institution.
7. You sought legal counsel that resulted in the cancellation of one or more of your student loans and have an invoice for services rendered and evidence of the cancellation of the student loan or loans. To qualify for STRF reimbursement, the application must be received within four (4) years from the date of the action or event that made the student eligible for recovery from STRF.
A student whose loan is revived by a loan holder or debt collector after a period of non-collection may, at any time, file a written application for recovery from STRF for the debt that would have otherwise been eligible for recovery. If it has been more than four (4) years since the action or event that made the student eligible, the student must have filed a written application for recovery within the original four (4) year period, unless the period has been extended by another act of law.
“It is important that you keep copies of your enrollment agreement, financial aid documents, receipts, or any other information that documents the amount paid to the school. Questions regarding the STRF may be directed to the Bureau for Private Postsecondary Education, 1747 N. Market Blvd. Ste 225 Sacramento, CA 95834, P.O. Box 980818 West Sacramento, CA 95798-0818 Website: www.bppe.ca.gov, telephone number (888) 370-7589.
However, no claim can be paid to any student without a social security number or a taxpayer identification number.”

Performance

SCHOOL PERFORMANCE FACT SHEET

CALENDAR YEARS 2022 & 2023

NURSING ASSISTANT, 160 Hours (SOC CODE: 31-1131)

On-Time Completion Rates (Graduation Rates)

Includes data for the two calendar years prior to reporting.

Calendar Year Number of Students Who Began the Program Students Available for Graduation Number of On-Time Graduates On-Time Completion Rate
202270706390.0%
202395959195.7%
Student’s Initials: *
Date: *

Initial only after you have had sufficient time to read and understand the information.

Students Completing Within 150% of the Published Program Length

Calendar Year Number of Students Who Began the Program Students Available for Graduation 150% Graduates 150% Completion Rate
202270706390.0%
202395959195.7%
Student’s Initials: *
Date: *

Initial only after you have had sufficient time to read and understand the information.

Job Placement Rates (includes data for the two calendar years prior to reporting)

Calendar Year Number of Students Who Began the Program Number of Graduates Graduates Available for Employment Graduates Employed in the Field Placement Rate % Employed in the Field
20227063634774.6%
20239591917481.3%

You may obtain from the institution a list of the employment positions determined to be in the field for which a student received education and training. You may request a copy from the school office.

Gainfully Employed Categories (includes data for the two calendar years prior to reporting)

Part-Time vs. Full-Time Employment

Calendar Year Graduate Employed in the Field 20-29 Hours per week Graduates Employed in the Field at Least 30 Hours per week Total Graduates Employed in the Field
202274047
202396574

Single Position vs. Concurrent Aggregated Position

Calendar Year Graduate Employed in the Field in a Single Position Graduates Employed in the Field in Concurrent Aggregated Positions Total Graduates Employed in the Field
202247047
202374074

Self-Employed/Freelance Positions

Calendar Year Graduates Employed who are Self-Employed or Working Freelance Total Graduates Employed in the Field
2022047
2023074

Institutional Employment

Calendar Year Graduates Employed in the Field who are Employed by the Institution, or an Employer who shares ownership with the institution. Total Graduates Employed in the Field
2022047
2023074
Student’s Initials: *
Date: *

Initial only after you have had sufficient time to read and understand the information.

License Examination Passage Rates (includes data for the two calendar years prior to reporting)

Calendar Year Number of Graduates in Calendar Year Number of Graduates Taking Exam Number Who Passed First Exam Number Who Failed First Available Exam Passage Rate
20226361471477%
2023918076495%

Licensure examination passage data is not available from the state agency administering the examination. We were able to collect data from all graduates.

Student’s Initials: *
Date: *

Initial only after you have had sufficient time to read and understand the information.

Salary and Wage Information (includes data for the two calendar years prior to reporting)

Annual salary and wages reported for graduates employed in the field.

Calendar Year Graduates Available for Employment Graduates Employed in the Field $15,001–$20,000 $20,001–$25,000 $25,001–$30,000 $30,001–$35,000 $35,001–$40,000 $45,001–$50,000
2022624703424123
202391743353323
Calendar Year $45,001–$50,000 $50,001–$55,000 $55,001–$60,000 $60,001–$65,000 $65,001–$70,000 $70,001–$75,000 No salary information reported
202210000018
2023214450021

A list of sources used to substantiate salary disclosures is available from the school. You can obtain a copy from the school office.

Student’s Initials: *
Date: *

Initial only after you have had sufficient time to read and understand the information.

Cost of Educational Program

  • Total charges for the program for students completing on-time in 2022: $1,635.00
  • Total charges may be higher for students that do not complete on time.
  • Total charges for the program for students completing on-time in 2023: $1,630.00
  • Total charges may be higher for students that do not complete on time.
Student’s Initials: *
Date: *

Initial only after you have had sufficient time to read and understand the information.

Students at INTERNATIONAL SCHOOL OF NURSING are not eligible for federal student loans. This institution does not meet the U.S. Department of Education criteria that would allow its students to participate in federal student aid programs.

Student’s Initials: *
Date: *

Initial only after you have had sufficient time to read and understand the information.

This fact sheet is filed with the Bureau for Private Postsecondary Education. Regardless of any information you may have relating to completion rates, placement rates, starting salaries, or license exam passage rates, this fact sheet contains the information as calculated pursuant to state law.

Any questions a student may have regarding this fact sheet that have not been satisfactorily answered by the institution may be directed to the Bureau for Private Postsecondary Education at 1747 N. Market Blvd, Suite 225, Sacramento, CA 95834, www.bppe.ca.gov, toll-free telephone number (888) 370-7589 or by fax (916) 263-1897.

Student Name – Print: *
Student Signature: *
Date: *
School Official:
Date:

Definitions

  • “Number of Students Who Began the Program” means the number of students who began a program who were scheduled to complete the program within 100% of the published program length within the reporting calendar year and excludes all students who cancelled during the cancellation period.
  • “Students Available for Graduation” is the number of students who began the program minus the number of students who have died, been incarcerated, or been called to active military duty.
  • “Number of On-Time Graduates” is the number of students who completed the program within 100% of the published program length within the reporting calendar year.
  • “On-Time Completion Rate” is the number of on-time graduates divided by the number of students available for graduation.
  • “150% Graduates” is the number of students who completed the program within 150% of the program length (includes on-time graduates).
  • “150% Completion Rate” is the number of students who completed the program in the reported calendar year within 150% of the published program length, including on-time graduates, divided by the number of students available for graduation.
  • “Graduates Available for Employment” means the number of graduates minus the number of graduates unavailable for employment.
  • “Graduates Unavailable for Employment” means the graduates who, after graduation, die, become incarcerated, are called to active military duty, are international students that leave the United States or do not have a visa allowing employment in the United States, or are continuing their education in an accredited or bureau-approved postsecondary institution.
  • “Graduates Employed in the Field” means graduates who, beginning within six months after a student completes the applicable educational program are gainfully employed, whose employment has been reported, and for whom the institution has documented verification of employment. For occupations for which the state requires passing an examination, the six months period begins after the announcement of the examination results for the first examination available after a student completes an applicable educational program.
  • “Placement Rate Employed in the Field” is calculated by dividing the number of graduates gainfully employed in the field by the number of graduates available for employment.
  • “Number of Graduates Taking Exam” is the number of graduates who took the first available exam in the reported calendar year.
  • “First Available Exam Date” is the date for the first available exam after a student completed a program.
  • “Passage Rate” is calculated by dividing the number of graduates who passed the exam by the number of graduates who took the reported licensing exam.
  • “Number Who Passed First Available Exam” is the number of graduates who took and passed the first available licensing exam after completing the program.
  • “Salary” is as reported by graduate or graduate’s employer.
  • “No Salary Information Reported” is the number of graduates for whom, after making reasonable attempts, the school was not able to obtain salary information.

STUDENT’S RIGHT TO CANCEL

The student has the right to cancel his or her enrollment agreement for a course of instruction, without any penalty or obligations, through attendance at the first class session, or the seventh day after enrollment, whichever is later. A student may not cancel by telephoning the school or not attending the class. After the end of cancellation period, the student also has the right to stop school at any time; and has the right to receive a pro rata refund if the student has completed 60 percent or less of the program less the registration fee, cost of book(s) and uniform. The refund is to be paid within 45 days after the cancellation date. Cancellation must be made in writing and the date the notice to withdraw is considered effective is on the date received by International School of Nursing. Cancellation must be delivered via U.S Postal Service or hand delivered to the following address:

Charles L. Weber, Administrator
International School of Nursing
1330 Springs Road, Vallejo CA 94591

DATE TO CANCEL

The student shall have until (Date of Cancellation) to receive a full refund.

Student Signature:
Date:

Convictions

INTERNATIONAL SCHOOL OF NURSING

1330 Springs Road, Vallejo, CA 94591 Tel. (707) 557-7173

CONVICTION OF PENAL CODE SECTION, WHICH CONSTITUTE AUTOMATIC DENIAL/ REVOCATION (HHA)

This is to certify that I received a copy and understand the list of convictions, which prohibit certification as indicated under the Disqualifying Penal Code Sections [ATCS 98-4 (11/09)]. HHA applicants with criminal convictions for any offence listed must provide evidence of good character and rehabilitation.

California Department of Public Health will evaluate HHA applicants with criminal convictions for any offence using its existing process in which CDPH requests that the applicant provide evidence of good character and rehabilitation. CDPH will review the information and either grant or deny criminal record clearance, based on the following criteria outlined in Health and Safety Codes section 1337.9 (c).

With my signature below, I affirm that I have read and understand the School’s conviction of Penal Code Section. I understand that providing false or misleading document is punishable by fine or imprisonment and may make me liable for denial for my criminal record clearance on the basis of the information and documents I have provided.

Disqualifying Penal Code Sections

ATCS 98-4 (11/09)

If they have been convicted of any of the penal codes listed, CNA/HHA applicants will be automatically denied certification.

Certification of applicants with convictions on this list MAY be reconsidered by the Department only if misdemeanor actions have been dismissed by a court of law or a Certificate of Rehabilitation has been obtained for felony convictions. Any other convictions, other than minor traffic violations, must also be reviewed.

Section
187 - Murder
192(a) - Manslaughter, Voluntary
203 - Mayhem
205 - Aggravated Mayhem
206 - Torture
207 - Kidnapping
209 - Kidnapping for ransom, reward, or extortion or robbery
210 - Extortion by posing as kidnapper
210.5 - False imprisonment
211 - Robbery (Includes degrees in 212.5 (a) and (b))
220 - Assault with intent to commit mayhem, rape, sodomy, oral copulation
222 - Administering stupefying drugs to assist in commission of a felony
243.4 - Sexual battery (Includes degrees (a) - (d))
245 - Assault with deadly weapon, all inclusive
261 - Rape(Includes degrees (a)-(c))
262 - Rape of spouse(Includes degrees (a)-(e))
264.1 - Rape or penetration of genital or anal openings by foreign object
265 - Abduction for marriage or defilement
266 - Inveiglement or enticement of female under 18
266a - Taking person without will or by misrepresentation for prostitution
266b - Taking person by force
266c - Sexual act by fear
266d - Receiving money to place person in cohabitation
266e - Placing a person for prostitution against will
266f - Selling a person
266g - Prostitution of wife by force
266h - Pimping
266i - Pandering
266j - Placing child under 16 for lewd act
266k - Felony enhancement for pimping/pandering
267 - Abduction of person under 18 for purposes of prostitution
273a - Willful harm or injury to a child; (Includes degrees (a)-(c))
273d - Corporal punishment/injury to a child (Includes degrees (a)-(c))
273.5 - Willful infliction of corporal injury (Includes (a)-(h))
285 - Incest
      
Section
286(c) - Sodomy with person under 14 years against will
(d) - Voluntarily acting in concert with or aiding and abetting in act of sodomy against will
(f) - Sodomy with unconscious victim
(g) - Sodomy with victim with mental disorder or developmental or physical disability
288 - Lewd or lascivious acts with child under age of 14
288a(c) - Oral copulation with person under 14 years against will
(d) - Voluntarily acting in concert with or aiding and abetting
(f) - Oral copulation with unconscious victim
(g) - Oral copulation with victim with mental disorder or developmental or physical disability
288.5 - Continuous sexual abuse of a child (Includes degree (a))
289 - Penetration of genital or anal openings by foreign object (Includes degrees (a)-(j))
289.5 - Rape and sodomy (Includes degrees (a) and (b))
368 - Elder or dependent adult abuse; theft or embezzlement of property (Includes (b)-(f))
451 - Arson (Includes degrees (a)-(e))
459 - Burglary (Includes degrees in 460 (a) and (b))
470 - Forgery (Includes (a)-(e))
475 - Possession or receipt of forged bills, notes, trading stamps, lottery tickets or shares (Includes degrees (a) - (c))
484 - Theft
484b - Intent to commit theft by fraud
484d-j - Theft of access card, forgery of access card, unlawful use of access card
487 - Grand theft (Includes degrees (a)-(d))
488 - Petty theft
496 - Receiving stolen property (Includes (a)-(c))
503 - Embezzlement
518 - Extortion
666 - Repeat convictions for petty theft, grand theft, burglary, carjacking, robbery and receipt of stolen property

Application Fee

$200.00