Form CDPH524 "Master's or Reciprocity Application for Nursing Home Administrator Examination" - California

What Is Form CDPH524?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the California Department of Public Health;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH524 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH524 "Master's or Reciprocity Application for Nursing Home Administrator Examination" - California

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California Department of Public Health (CDPH)
State of California – Health and Human Services Agency
Nursing Home Administrator Program (NHAP)
P.O. Box 997416, MS 3302
Sacramento, CA 95899-7416
(916) 552-8780 FAX (916) 636-6108
NHAP@cdph.ca.gov
In this space, attach a recent
photo (within previous 90 days),
Master’s or Reciprocity Application for
sized appr oximat ely 2" by 2" ,
clearly picturing the applicant’s
Nursing Home Administrator Examination
face.
Return this completed form with a check or money order (made payable to NHAP) with the appropriate fee to the
following address:
(FOR IDENTIFICATION
PURPOSES ONLY)
Nursing Home Administrator Program
P.O. Box 997416, MS 3302
Sacramento, CA 95899-7416
For a current Fee List and Detailed Fee Analysis, please visit our website at:
www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/NHAPFees.aspx
APPLICANT’S NAME (Last)
(First)
(M.I)
SOCIAL SECURITY NUMBER*
CURRENT ADDRESS (If P.O. Box, must provide street address)
(City)
(State)
(Zip Code)
PERMANENT MAILING ADDRESS (If different from address listed above)
(City)
(State)
(Zip Code)
BUSINESS MAILING ADDRESS
(City)
(State)
(Zip Code)
IDENTIFY PREFERRED PUBLIC RECORD ADDRESS
DAYTIME TELEPHONE NUMBER
EVENING TELEPHONE NUMBER
Current
Permanent
Business
DATE OF BIRTH (MM/DD/YYYY)
E-MAIL
FAX NUMBER (Optional)
Please identify the way you would like your name to appear on you license: (First, Middle, Last)
*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 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, collection of delinquent State taxes if applicant appears on the Franchise Tax Board’s top 500 delinquent taxpayers list pursuant to Business
Codes Section 494.5 Subdivision (4), and for reporting disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR Section 61.1 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.
ANSWER THE FOLLOWING QUESTIONS:
1. Are you now, or were you, employed as a Nursing Home Administrator in any other state within the U.S.?
Yes
No
(If “Yes”, fill in the information below. Provide each State with certification on the Verification of Nursing Home Administrator
License page.)
State:
License #:
Date of expiration:
State:
License #:
Date of expiration:
State:
License #:
Date of expiration:
2. Former names? (If “Yes” List in space below)
Yes
No
a.
b.
c.
3. State Examination Date Requested: _________________________________
CERTIFICATION – IMPORTANT – PLEASE READ BEFORE SIGNING – If not signed, this application may be rejected.**
I certify under penalty of the perjury laws of the State of California that the information I have entered on this application is true and correct. I further understand that failure to disclose requested
information or any false, incomplete, or incorrect statements may result in denial of this application and/or disqualification from the State Examination and/or applying through reciprocity with the
NHAP. I authorize the employers, U.S. State Agencies and educational institutions identified on this application to release any information they may have concerning my licensure, disciplinary
records, employment or education to the State of California NHA P. I also understand that all the fees are non-refundable and non-transferable and will be forfeited.
APPLICANT’S SIGNATURE : _____________________________________________________________________________________
DATE : ________________________
APPLICANTS – DO NOT USE THE SPACE BELOW – FOR NHAP USE ONLY
STATUS
Approved
Rejected
Denied
Missing Information
Correct Fees
State Certification
CASH #
Fingerprints/Live Scan
Provisional License #
NHAP INITIALS
STAFF
DATE PROCESSED
Unopened Transcripts
AMOUNT
CDPH 524 (01/20)
Page 1 of 4
California Department of Public Health (CDPH)
State of California – Health and Human Services Agency
Nursing Home Administrator Program (NHAP)
P.O. Box 997416, MS 3302
Sacramento, CA 95899-7416
(916) 552-8780 FAX (916) 636-6108
NHAP@cdph.ca.gov
In this space, attach a recent
photo (within previous 90 days),
Master’s or Reciprocity Application for
sized appr oximat ely 2" by 2" ,
clearly picturing the applicant’s
Nursing Home Administrator Examination
face.
Return this completed form with a check or money order (made payable to NHAP) with the appropriate fee to the
following address:
(FOR IDENTIFICATION
PURPOSES ONLY)
Nursing Home Administrator Program
P.O. Box 997416, MS 3302
Sacramento, CA 95899-7416
For a current Fee List and Detailed Fee Analysis, please visit our website at:
www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/NHAPFees.aspx
APPLICANT’S NAME (Last)
(First)
(M.I)
SOCIAL SECURITY NUMBER*
CURRENT ADDRESS (If P.O. Box, must provide street address)
(City)
(State)
(Zip Code)
PERMANENT MAILING ADDRESS (If different from address listed above)
(City)
(State)
(Zip Code)
BUSINESS MAILING ADDRESS
(City)
(State)
(Zip Code)
IDENTIFY PREFERRED PUBLIC RECORD ADDRESS
DAYTIME TELEPHONE NUMBER
EVENING TELEPHONE NUMBER
Current
Permanent
Business
DATE OF BIRTH (MM/DD/YYYY)
E-MAIL
FAX NUMBER (Optional)
Please identify the way you would like your name to appear on you license: (First, Middle, Last)
*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 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, collection of delinquent State taxes if applicant appears on the Franchise Tax Board’s top 500 delinquent taxpayers list pursuant to Business
Codes Section 494.5 Subdivision (4), and for reporting disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR Section 61.1 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.
ANSWER THE FOLLOWING QUESTIONS:
1. Are you now, or were you, employed as a Nursing Home Administrator in any other state within the U.S.?
Yes
No
(If “Yes”, fill in the information below. Provide each State with certification on the Verification of Nursing Home Administrator
License page.)
State:
License #:
Date of expiration:
State:
License #:
Date of expiration:
State:
License #:
Date of expiration:
2. Former names? (If “Yes” List in space below)
Yes
No
a.
b.
c.
3. State Examination Date Requested: _________________________________
CERTIFICATION – IMPORTANT – PLEASE READ BEFORE SIGNING – If not signed, this application may be rejected.**
I certify under penalty of the perjury laws of the State of California that the information I have entered on this application is true and correct. I further understand that failure to disclose requested
information or any false, incomplete, or incorrect statements may result in denial of this application and/or disqualification from the State Examination and/or applying through reciprocity with the
NHAP. I authorize the employers, U.S. State Agencies and educational institutions identified on this application to release any information they may have concerning my licensure, disciplinary
records, employment or education to the State of California NHA P. I also understand that all the fees are non-refundable and non-transferable and will be forfeited.
APPLICANT’S SIGNATURE : _____________________________________________________________________________________
DATE : ________________________
APPLICANTS – DO NOT USE THE SPACE BELOW – FOR NHAP USE ONLY
STATUS
Approved
Rejected
Denied
Missing Information
Correct Fees
State Certification
CASH #
Fingerprints/Live Scan
Provisional License #
NHAP INITIALS
STAFF
DATE PROCESSED
Unopened Transcripts
AMOUNT
CDPH 524 (01/20)
Page 1 of 4
APPLICANT’S NAME (Last)
(First)
(M.I.)
SOCIAL SECURITY NUMBER**
4. Are you now, or have your ever been licensed or certified by any other California State Agency? (If “Yes,” please complete
Yes
No
below.)
Agency:
License #:
Date of expiration:
Agency:
License #:
Date of expiration:
Agency:
License #:
Date of expiration:
5. Have you ever pled guilty or nolo contendere to, or been convicted of, any crime (other than minor traffic violations)?
Yes**
No
** IF THE ANSWER TO THIS QUESTION IS YES, EXPLAIN FULLY ON A SHEET OF PAPER. PROVIDE CERTIFIED COPIES OF ARREST
REPORT AND COURT DOCUMENTS THAT INCLUDE THE FOLLOWING AS APPLICABLE: CRIMINAL COMPLAINT, PLEA AND JUDGMENT,
AND PROBATION REPORT. IF THESE RECORDS HAVE BEEN DESTROYED, THE PROGRAM REQUIRES A SIGNED STATEMENT TO THAT
FACT FROM THE AGENCY YOU ARE REQUESTING YOUR INFORMATION. A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU.
6. Have you ever allowed your NHA license to lapse, or had a temporary license issued by any state licensing authority?
Yes
No
If “Yes”, identify the State Agency, license name and number:
_______________________________________________________________________
7. Have you ever voluntarily surrendered any other professional license?
Yes
No
8. Have you ever been the subject of disciplinary action by any licensing agency with regard to any other professional license?
Yes
No
If “Yes,” provide detailed explanation on separate sheet of paper and attach to this application package.
9. Within the last five (5) years have you had a license or certification revoked or suspended, other disciplinary action taken or
Yes
No
an application for licensure or certification refused, revoked or suspended by any professional licensing authority of another
State, Territory or Country?
If “Yes,” identify the agency, state license name, number and reason:
______________________________________________________________
10. If required because of a subpoena for NHA licensure records, can you provide adequate documentation for any of the answers
Yes
No
you provided above?
11. On which basis are you applying for the Nursing Home Administrator Exam (Check one)?
Master’s degree in Nursing Home Administration or a related Health Administration field, with an internship/residency in a Long-Term Care
Facility.
Current licensure as a Nursing Home Administrator in another state.
12.
EDUCATION
DID YOU GRADUATE FROM HIGH SCHOOL?
IF NOT, DID YOU POSSESS A GED OR EQUIVALENT?
IF NOT, ENTER THE HIGHEST GRADE YOU COMPLETED:
Yes
No
Yes
No
____________________
UNIVERSITY OR COLLEGE NAME-AND
UNITS
DIPLOMA, DEGREE OR
LOCATION, BUSINESS, CORRESPONDENCE,
COURSE
DATE COMPLETED
CERTIFICATE OBTAINED
SEMESTER
QUARTER
TRADE, TECHNICAL, OR SERVICE SCHOOL
13.
MASTER’S DEGREE WITH INTERNSHIP
EXACT TITLE OF MASTER’S DEGREE
Yes
No
WAS YOUR INTERNSHIP IN A LONG-TERM FACILITY?
NAME AND ADDRESS OF THE FACILITY
NUMBER OF WEEKS
NUMBER OF HOURS PER WEEK
BRIEFLY DESCRIBE YOUR INTERNSHIP PROGRAM (Attach an extra sheet if necessary)
CDPH 524 (01/20)
Page 2 of 4
APPLICANT’S NAME (Last)
(First)
(M.I.)
SOCIAL SECURITY NUMBER**
14.
SPECIALIZED TRAINING
List in chronological order, from date of graduation from any professional school or program to the present, all professional post-graduate not including continuing education
coursework (i.e. residency, vocational training, practical or clinical training).
DATES OF ATTENDANCE
DID YOU
LOCATION
INSTITUTION NAME
COMPLETE
FROM
TO
(City and State or County)
TRAINING?
(MONTH/YEAR)
(MONTH/YEAR)
15.
CITIZENSHIP (Health and Safety Code 1416.22 (a))
(a)
Are you a United States Citizen?
Yes
No
(b)
Are you a Legal Resident?
Yes
No
(c)
Are you at least eighteen (18) years of age or older?
Yes
No
16.
FAMILY SUPPORT
In accordance with the Welfare and Institutions Code Section 11350.6, applications for renewal of a license or a new license shall include the applicant’s Social Security
Number, and the licensee shall certify, under penalty of perjury, that he or she is not more than thirty (30) calendar days delinquent in complying with a child support order,
order for spousal support or alimony or repayment obligation. Failure to certify may result in disciplinary or adverse action, and making a false statement may subject the
licensee to denial or revocation of provisional license.
You must check one of the following:
I am not more than
days delinquent in complying with a child support order/order for spousal support or alimony/educational loan repayment obligation.
I am more than
days delinquent in complying with a child support order/order for spousal support or alimony/educational loan repayment obligation.
I am currently in compliance with a family support order.
I am not currently under any child support order/spousal support or alimony or repayment obligation.
17.
Yes
No
Do you have a job offer for a NHA position with a nursing home or long-term care facility in the State of California?
If “Yes”, please provide facility and contact information below (To be completed by facility employer):
APPLICANT’S NAME (Last)
(First)
(Middle)
FACILITY PHONE NUMBER
JOB TITLE OFFERED
DATE TO BEGIN
NAME OF FACILITY, OFFICE OR CORPORATION
TELEPHONE NUMBER
ADDRESS OF FACILITY, OFFICE OR CORPORATION (NUMBER AND STREET)
(City)
(State)
(Zip Code)
NAME OF SNF/ICF WHERE JOB WILL BE HELD
TELEPHONE NUMBER
ADDRESS OF SNF/ICF WHERE JOB WILL BE HELD (NUMBER AND STREET)
(City)
(State)
(Zip Code)
CONTACT PERSON AT FACILITY (Name and Title)
TELEPHONE NUMBER
I have reviewed the application package, and it is complete with necessary attachments listed below.
2 X 2 Photo
Criminal Conviction Documentation (if applicable)
Live Scan
Facility Employer Section Completed (16)
Certification form from each state of licensure
Official Transcripts (unopened)
I declare under penalty of perjury under the laws of the State of California that the information furnished in this application is true and correct. By virtue of filing this application, I do
solemnly swear or affirm that I am of good moral character, and that I understand the instructions and terms as set forth in this application form, that I have personally completed this form,
that the information given in this application is true, correct, and that the photograph attached hereto is a true likeness of myself. I hereby authorize the State of California to verify any and
all information contained in this application, including information maintained in applicable data banks, and to transmit this information to the licensing authority of the state to which this
application is made. I authorize the licensing authority of the State of California to review state files pertaining to my licensure and practice, and all law enforcement records, administrative
records, and court documents to confirm the accuracy and completeness of the information provided herein. This application and signature shall act as authorization of entities in
possession of applicable information to release such information to the licensing authority.
APPLICANT’S SIGNATURE: _____________________________________________________________________________________
DATE: ____________________
CDPH 524 (01/20)
Page 3 of 4
VERIFICATION OF NURSING HOME
ADMINISTRATOR LICENSE
TO THE APPLICANT:
If you are applying for the California reciprocity on the basis of your licensure in another state, please have the following certification verification completed by the licensing
board of the state in which you are currently licensed, and all other states in which you have ever held a license as a nursing home administrator. (Duplication of this page is
permitted.
TO THE STATE BOARD, PROGRAM OR LICENSING AGENCY IN WHICH THE BELOW NAMED APPLICANT IS OR EVER HAS BEEN LICENSED:
is applying for licensure as a nursing home administrator in California. Please furnish the following information concerning the applicant.
(Name)
APPLICANT’S SIGNATURE (AS SHOWN ON YOUR RECORDS)
DATE OF BIRTH (MM/DD/YYYY)
SOCIAL SECURITY NUMBER
ORIGINAL LICENSE NUMBER
DATE ISSUED
EXPIRATION DATE
1.
Has the licensee ever had any application for any professional license refused or denied by your licensing authority?
Yes
No
2.
Has the licensee ever been refused or denied the privilege of taking an examination required for any professional licensure?
Yes
No
3.
Has the licensee ever been dropped, suspended, placed on probation, fined or requested to resign license in lieu of adverse
Yes
No
action by your state’s licensing authority?
If “Yes,” list offense, duration of discipline, discipline type, date(s) of discipline and completion date(s):
4.
Has the applicant’s NHA license ever been revoked?
Yes
No
5.
Has the licensee ever been the subject of disciplinary action with regard to your state’s NHA license,
been sanctioned by any other licensing authority, association, licensed facility, or staff of such facility?
Yes
No
6.
Are there any unresolved or pending complaints against the licensee with any licensing agency in your state?
Yes
No
Length of time needed to resolve these:
7.
The number, type and date(s) of complaints filed against licensee:
8.
Does the applicant comply with your state’s regulatory requirements governing long-term care administrators or facilities?
Yes
No
9.
Were any citations issued against the licensee? Number of citations that were upheld against the licensee:
Yes
No
Citation level (AA, A, B, etc.):
10. Candidate’s National Examination score
:
11. Did licensee complete an Administrator-in-Training Program in your state?
Yes
No
If “Yes,” number of hours completed:
12. What is/was the licensee’s length of time licensed in your state?
13. Is the licensee a preceptor in your state?
Yes
No
14. Is the licensee’s Continuing Education current?
Yes
No
SIGNATURE OR EXECUTIVE OFFICER OR DIRECTOR
DATE SIGNED
NAME OF EXECUTIVE OFFICER (PLEASE PRINT OR TYPE)
AGENCY NAME
ADDRESS (Number and Street)
(City)
(State)
(Zip Code)
TELEPHONE NUMBER
FAX NUMBER
WEBSITE
E-MAIL ADDRESS
STATE BOARD: PLEASE COMPLETE AND RETURN FORM DIRECTLY TO:
NURSING HOME ADMINISTRATOR PROGRAM
P.O. BOX 997416, MS 3302
STATE
SACRAMENTO, CA 95899-7416
SEAL
HERE
CDPH 524 (01/20)
Page 4 of 4
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