Form CDPH E276C "Online Nurse Assistant Certification Training Program Individual Student Record" - California

What Is Form CDPH E276C?

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 December 1, 2019;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH E276C 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 CDPH E276C "Online Nurse Assistant Certification Training Program Individual Student Record" - California

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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)
eLearning Review Unit (ELRU)
Email: eLearning@cdph.ca.gov
Online Nurse Assistant Certification Training Program Individual Student Record
Please submit completed form to the eLearning Review Unit at
eLearning@cdph.ca.gov
*Social Security Number
Student Name
Start Date
Completion Date
Instructor Name (Printed)
Instructor Signature
Date
Final Grade
Instructor: Date and initial in each theory section when student completes required theory training.
THEORY
CONTENT
TEST
SCORES
Per 42 CFR 483.152(b)(1), at least a total of 16 hours of training in the following
areas [must be provided] prior to direct contact with a resident.
Federal requirement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Title 22 equivalent
(i) Communications and interpersonal skills. . . . . . . . . . . .
Modules 1, 3
(ii) Infection control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Modules 6
HOURS
DATE
INITIALS
(iii) Safety and emergency procedures, including the Heimlic
h maneuver.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Modules 4, 5, 12
(iv) Promoting residents’ independence . . . . . . . . . . . . . . . . . .
Module 14
(v) Respecting residents' rights . . . . . . . . . . . . . . . . . . . . .
Module 2
MODULE 1: Introduction (2 hours)
A) Roles and responsibilities of a Certified Nurse Assistant (CNA)
B) Title 22, Division 5, California Code of Regulations, overview
C) Requirements for nurse assistant certification
D) Professionalism
E) Ethics and confidentiality
MODULE 2: Patients’ Rights (3 hours total)
A) Title 22 Section 72527
B) Health and Safety Code Sections 1599.1, 1599.2, 1599.3
C) Code of Federal Regulations Part 483 Sections 483.10, 483.12, 483.13,
and 483.15
D) Preventing, recognizing, and reporting residents’ right violations. (1 hour
required for this component)
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 Health Integrity and Protection Date Bank as required by 45, CFR §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 examination identification, for identification purposes in national disciplinary databases or as the basis of a disciplinary
.
action against you
CDPH E276C (12/19)
This form is available at the
elearning Review Unit
website
1 of 5
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)
eLearning Review Unit (ELRU)
Email: eLearning@cdph.ca.gov
Online Nurse Assistant Certification Training Program Individual Student Record
Please submit completed form to the eLearning Review Unit at
eLearning@cdph.ca.gov
*Social Security Number
Student Name
Start Date
Completion Date
Instructor Name (Printed)
Instructor Signature
Date
Final Grade
Instructor: Date and initial in each theory section when student completes required theory training.
THEORY
CONTENT
TEST
SCORES
Per 42 CFR 483.152(b)(1), at least a total of 16 hours of training in the following
areas [must be provided] prior to direct contact with a resident.
Federal requirement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Title 22 equivalent
(i) Communications and interpersonal skills. . . . . . . . . . . .
Modules 1, 3
(ii) Infection control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Modules 6
HOURS
DATE
INITIALS
(iii) Safety and emergency procedures, including the Heimlic
h maneuver.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Modules 4, 5, 12
(iv) Promoting residents’ independence . . . . . . . . . . . . . . . . . .
Module 14
(v) Respecting residents' rights . . . . . . . . . . . . . . . . . . . . .
Module 2
MODULE 1: Introduction (2 hours)
A) Roles and responsibilities of a Certified Nurse Assistant (CNA)
B) Title 22, Division 5, California Code of Regulations, overview
C) Requirements for nurse assistant certification
D) Professionalism
E) Ethics and confidentiality
MODULE 2: Patients’ Rights (3 hours total)
A) Title 22 Section 72527
B) Health and Safety Code Sections 1599.1, 1599.2, 1599.3
C) Code of Federal Regulations Part 483 Sections 483.10, 483.12, 483.13,
and 483.15
D) Preventing, recognizing, and reporting residents’ right violations. (1 hour
required for this component)
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 Health Integrity and Protection Date Bank as required by 45, CFR §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 examination identification, for identification purposes in national disciplinary databases or as the basis of a disciplinary
.
action against you
CDPH E276C (12/19)
This form is available at the
elearning Review Unit
website
1 of 5
ONLINE NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM INDIVIDUAL STUDENT RECORD
Student Name (Printed)
Instructor Signature
Date
THEORY
TEST
CONTENT
SCORES
HOURS
INITIALS
DATE
MODULE 3: Interpersonal Skills (2 hours)
A) Communications
B) Defense mechanisms
C) Sociocultural factors
D) Attitudes toward illness and health care
E) Family interaction
MODULE 4: Prevention and Management of Catastrophe and Unusual
Occurrences (1 hour)
A) Emergency
B) General safety rules
C) Fire and disaster plans
D) Roles and procedures for Certified Nurse Assistants (CNA)
E) Patient Safety
MODULE 5: Body Mechanics (2 hours)
A) Basic rules of body mechanics
B) Transfer techniques
C) Ambulation
D) Proper use of body mechanics and positioning techniques
MODULE 6: Medical and Surgical Asepsis (2 hours)
A)
Micro-organisms
B)
Universal precautions (Standard Precautions)
C) Basic principles of asepsis
MODULE 7: Weights and Measures (1 hour)
A) The metric system
B) Weight, length, and liquid volume
C) Military time, i.e. a 24-hour clock
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CDPH E276C (12/19)
This form is available at the
eLearning Review Unit
website
ONLINE NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM INDIVIDUAL STUDENT RECORD
Student Name (Printed)
Instructor Signature
Date
THEORY
TEST
CONTENT
SCORES
HOURS
DATE
INITIALS
MODULE 8: Patient Care Skill (14 hours)
A) Bathing and medicinal baths
B) Dressing
C) Oral hygiene
D) Hair care, hair shampoo, medicinal shampoo, nail care, and shaving
E) Prosthetic devices
F) Skin care including prevention of decubitus ulcers
G) Elimination needs
H) Bowel and bladder retraining
I) Weighing and measuring the patient
MODULE 9: Patient Care Procedures (7 hours)
A) Collection of specimens, including stool, urine, and sputum
B) Care of patients with tubing to include but not be limited to urinary, gastric,
oxygen and intravenous. This care does not include inserting, suctioning, or
changing the tubes.
C) Intake and Output
D) Bedmaking
E) Cleansing enemas and laxative suppositories
F) Admission, transfer and discharge
G) Bandages and nonsterile dry dressings, including the application of
nonlegend topical ointments to intact skin surfaces
MODULE 10: Vital Signs (3 hours)
A) Purpose of vital signs
B) Factors affecting vital signs
C) Normal ranges
D) Methods of measurement
E) Temperature, pulse, respiration
This form is available at the
eLearning Review Unit
website
3 of 5
CDPH E276C (12/19)
ONLINE NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM INDIVIDUAL STUDENT RECORD
(Printed)
Instructor Signature
Date
Student Name
THEORY
TEST
CONTENT
SCORES
HOURS
DATE
INITIALS
MODULE 10: Vital Signs (3 hours) Continued
F) Blood pressure
G) Abnormalities
H) Recording
MODULE 11: Nutrition (2 hours)
A) Proper nutrition
B) Feeding techniques
C) Diet therapy
MODULE 12: Emergency Procedures (2 hours)
A) Signs and symptoms of distress
B) Immediate and temporary intervention
C) Emergency codes
MODULE 13: Long-Term Care Patient
SNF/ICF (5 hours)
Non-SNF/ICF (3 hours)
A) Special needs of persons with
A1) Special needs of persons with
developmental and mental disorders
developmental and mental
including intellectual disability,
disorders Including intellectual
Alzheimer’s disease, cerebral palsy,
disability, cerebral palsy, epilepsy,
epilepsy, dementia, Parkinson’s disease,
Parkinson’s disease, and mental
and mental illness. (2 hours)
illness. (2 hours)
A2) Special needs of persons with
**See footnote below
Alzheimer’s disease and related
dementias (2 hours)
B) Introduction to anatomy and
B) Introduction to anatomy and
physiology (B-F Minimum 1 hour)
physiology (B-F Minimum 1 hour)
C) Physical and behavioral needs
C) Physical and behavioral needs and
and changes
changes
D) Community resources available
D) Community resources available
E) Psychological, social, and
E) Psychological, social, and
recreational needs
recreational needs
F) Common diseases and disorders
F) Common diseases and disorders
including signs and symptoms
including signs and symptoms
**Non-SNF/ICF providers may complete A2, or any 2 hours of training from another module in order to meet the 60
hour minimum theory training requirement. (2 hours)
CDPH E276C (12/19)
This form is available at the
eLearning Review Unit
website
4 of 5
ONLINE NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM INDIVIDUAL STUDENT RECORD
Student Name (Printed)
Instructor Signature
Date
THEORY
TEST
CONTENT
SCORES
HOURS
DATE
INITIALS
MODULE 14: Rehabilitative Nursing (2 hours)
A) Promoting patients' potential
B) Devices and equipment
C) Activities of daily living
D) Family interactions
E) Complication of inactivity
F) Ambulation
G)Range of motion
MODULE 15: Observation and Charting (4 hours)
A) Observation of patients and reporting responsibility
B) Patient care plan
C) Patient care documentation
D) Legal issues of charting
E) Medical terminology and abbreviations
MODULE 16: Death and Dying (2 hours)
A) Stages of grief
B) Emotional and spiritual needs of the patient and family
C) Rights of the dying patient
D) Signs of approaching death
E) Monitoring of the patient
F) Post mortem care
MODULE 17: Abuse (as per HSC 1337.1 and 1337.3) (6 hours)
A) Preventing, recognizing and reporting instances of resident abuse.
Pursuant to Section 71835(l), all records pertaining to individuals who have successfully completed the program shall be
available for the Department’s inspection for a period of four (4) years beginning from the date of enrollment. Compliance
with the Bureau for Private Postsecondary Education requires that all student records (including those who do not
complete the course) must be kept for five (5) years from the date of enrollment.
This form is available at the
eLearning Review Unit
website
CDPH E276C (12/19)
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