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MS 0500 to Default, California Conference of Local Health Officers, Communicable Disease Control And Prevention, Chronic Disease Injury Prevention Agenda 1-5-2017, Chronic Disease Injury Prevention Agenda 2-15-2017, Chronic Disease Injury Prevention Agenda 3-2-2017, Center for Chronic Disease Prevention and Health Promotion, Division of Chronic Disease and Injury Control, Tobacco Education and Research Oversight Committee, Preventive Medicine Public Health Residency Program, California Epidemiologic Investigation Service Fellowship Program, California Stroke Registry-California Coverdell Program, Guidelines, Resources, and Evidence-Based Best Practices for Providers, Chronic Disease Surveillance and Research Branch, California Comprehensive Cancer Control Program, California's Comprehensive Cancer Control Plan, Domestic Violence/Intimate Partner Violence, Child Passenger Safety (CPS) In California, Drowning Prevention: Toddler Pool and Spa Safety, Nutrition Education and Obesity Prevention Branch, SNAP-Ed Guidance for Local Health Departments, Division of Environmental and Occupational Disease Control, Childhood Lead Poisoning Prevention Branch, Environmental Health Investigations Branch, Community Participation & Education Section, About the Environmental Health Laboratory, CDPH-Approved Cholinesterase Laboratories, Contact the Environmental Health Laboratory, Occupational Health Branch Programs and Activities, Occupational Health Branch Publications & Videos, What's New at the Occupational Health Branch, Work-Related Valley Fever (Coccidioidomycosis), Occupational Health Watch April 2017: Spotlight on Skylight Falls for Workers Memorial Day, Occupational Health Watch July 2016: August Is Valley Fever Awareness Month, Substance Addiction and Prevention Branch, Division of Food, Drug, and Cannabis Safety, FDLB Chemistry and Microbiology Client List, Abused Substances Analysis Section (ASAS), Division of Radiation Safety and Environmental Management, Radiologic Technology Certification Committee, Certificates, Licenses, Permits and Registrations, Genetic Disease Screening Program Publications, GDSP Notice Of Information And Privacy Practices, Maternal, Child and Adolescent Health Division, AFLP RFA 2020: Public Notice of Intent to Award, AFLP Request for Applications #20-10014, Addendum #9, AFLP Request for Applications #20-10014, Addendum #10, AFLP RFA 2020: Final Announcement of Awards, Program Consultants and Contract Managers, Where We Are: Local BIH Sites and Coordinators, Guidelines and Resources for Community Partners, Breastfeeding Model Hospital Policy Recommendations, Lactation Accommodation: For Child Care Providers, Lactation Accommodation: For Community Partners, In-Hospital Breastfeeding Initiation Data, Lactation Accommodation Laws for Workplace, Jails and School, California Personal Responsibility Education Program, CA PREP Questions and Answers for 2018 RFA, CA PREP Program Consultants and Contract Managers, Human Stem Cell Research Advisory Committee, I&E Program Consultants and Contract Managers, Local Maternal, Child and Adolescent Health, Emergency Preparedness: Infant and Young Child Feeding, Healthy Weight for Healthy Birth and Beyond, Multiple Factors Affect Birthing Parents’ Weight, Regional Perinatal Programs of California, Where We Are: Local RPPC Sites and Coordinators, Resources for Hospital and Health Care Providers, California Maternal Quality Improvement Toolkit, CMQCC Improving Health Care Response to Maternal Venous Thromboembolism, CMQCC Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum, Sudden Infant Death Syndrome (SIDS) Program, Title V Maternal and Child Health Block Grant, MonitoringAdherenceToHCPracticesThatPreventInfection, Healthcare Personnel Influenza Vaccination Reporting In CA Hospitals, CA Campaign To Prevent BSI in Hemodialysis Patients, Central Line-associated Blood Stream Infection (CLABSI), Methicillin-Resistant Staphylococcus aureus Bloodstream Infection (MRSA BSI), Vancomycin-resistant Enterococci Bloodstream Infection (VRE BSI), Center for Health Statistics and Informatics, California Marriage License, Registration and Ceremony Information, Vital Records Obtaining Certified Copies of Death Records, Obtaining Vital Records From County Offices, Vital Records Issuance and Preservation Branch, California Marriage License General Information, HIV/AIDS ADAP Health Insurance Premium Payment Assistance, HIV/AIDS ADAP Medicare Part D Premium Payment Assistance, About the Viral and Rickettsial Disease Lab, Communicable Disease Emergency Response Program, DCDC Information for Local Health Departments, Sexually Transmitted Diseases Control Branch, VRDL Guidelines for Specimen Collection and Submission for Pathologic Testing, Office of Binational Border Health Publications, Office of Binational Border Health Advisory Group, About the Office of Binational Border Health, Contact the Office of Binational Border Health, Quarterly Binational Epidemiology Meetings, Border Infectious Disease Surveillance - Coccidioidomycosis, Border Infectious Disease Surveillance - Queso Fresco, Border Infectious Disease Surveillance - Mosquito-borne-diseases, Border Infetious Disease Surveillance - Rocky Mountain Spotted Fever, Border Infectious Disease Surveillance - Influenza and Other Respiratory Infections, Emergency and Evacuation Planning Guide for Schools, Tips for Communicating with Students During an Emergency, Know When and How to Shelter-in-Place for Schools, How to Help Students Cope and Deal with Stress, Pandemic Flu Preparedness For Schools - Home, Fusion Center (Strategic Development and External Relations), Office of Health Equity - Health Equity Policy & Planning Unit, Climate Change and Health Equity Program (CCHEP), Office of Health Equity Advisory Committee, Health Research and Statistics Unit (HRSU), CDPH Climate Change and Health Profile Reports, CDPH Climate Change and Health Vulnerability Indicators, Office of Legislative and Governmental Affairs, CDPH Lifts Rock Crab Health Advisory in Portions of San Mateo County - South of Pillar Point, CDPH Launches Mobile Website for WIC Participants, CDPH Reports Widespread Flu Activity that is More Severe than Last Year, CDPH Fines San Francisco County Facility in Death of Resident, CDPH Fines Los Angeles County Facility in Death of Resident, Let’s Get Healthy California Announces Local Innovations to Improve California’s Health, Dungeness Crab Health Advisory Lifted for Remainder of California Coast, Dungeness Crab Health Advisory Lifted in Portions of Mendocino County – South of Ten Mile River, CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from San Luis Obispo County, Dungeness Crab Health Advisory Lifted in Portions of Sonoma, Mendocino, Humboldt Counties, CDPH Releases Reports on Healthcare-Associated Infections, Influenza Vaccination Rates Among Healthcare Personnel, CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from Monterey County, CDPH Awarded Grant to Expand Child Safety-Seat Use, CDPH Awarded Grant to Study Motor-Vehicle Crash Injuries, Holiday Travelers Reminded to Take Precautions to Prevent Zika, Local Transmission Confirmed in Ensenada, Mexico, Office of Quality Performance and Accreditation, Meet the Former Interns - Yesenia Posadas, Office of the State Public Health Laboratory Director, California Laboratory Animal Use Approval Program, Job Opportunities - Laboratory Field Services, Complaints Program - Laboratory Field Services, Clinical Laboratory Technology Advisory Committee (CLTAC), Clinical Laboratory Scientist Trainee License, Clinical Chemist Scientist Trainee License, Clinical Cytogeneticist Scientist Trainee License, Clinical Genetic Molecular Biologist Scientist Trainee License, Clinical Hematologist Scientist Trainee License, Clinical Histocompatibility Scientist Trainee License, Clinical Immunohematologist Scientist Trainee License, Clinical Microbiologist Scientist Trainee License, Clinical Toxicologist Scientist Trainee License, Clinical Laboratory Professional Licensing, Renewal of Clinical Laboratory Personnel Licenses & Certificates, Personnel License Changes & Duplicate Requests, Statement of CDPH HIPAA Covered Entity Status, DPH-16-015E Newborn Screening Fee Increase, DPH-16-016E Prenatal (Multiple Marker) Screening Program, DPH-05-012 Forensic Alcohol Testing Laboratories, DPH-11-004 Pre-Kindergarten and School Immunization Requirements, DPH-17-004 Medical Cannabis Manufacturing, EXEMPT-11-011 Tissue Donors HIV Sperm Washing, Forms: Licensing and Certification Program, en A.10.a. Fill out, securely sign, print or email your CDPH 5000 - California Department of Public Health - State of ... - cdph ca instantly with SignNow. Available for PC, iOS and Android. to Default, California Conference of Local Health Officers, Communicable Disease Control And Prevention, Chronic Disease Injury Prevention Agenda 1-5-2017, Chronic Disease Injury Prevention Agenda 2-15-2017, Chronic Disease Injury Prevention Agenda 3-2-2017, Center for Chronic Disease Prevention and Health Promotion, Division of Chronic Disease and Injury Control, Tobacco Education and Research Oversight Committee, Preventive Medicine Public Health Residency Program, California Epidemiologic Investigation Service Fellowship Program, California Stroke Registry-California Coverdell Program, Guidelines, Resources, and Evidence-Based Best Practices for Providers, Chronic Disease Surveillance and Research Branch, California Comprehensive Cancer Control Program, California's Comprehensive Cancer Control Plan, Domestic Violence/Intimate Partner Violence, Child Passenger Safety (CPS) In California, Drowning Prevention: Toddler Pool and Spa Safety, Nutrition Education and Obesity Prevention Branch, SNAP-Ed Guidance for Local Health Departments, Division of Environmental and Occupational Disease Control, Childhood Lead Poisoning Prevention Branch, Environmental Health Investigations Branch, Community Participation & Education Section, About the Environmental Health Laboratory, CDPH-Approved Cholinesterase Laboratories, Contact the Environmental Health Laboratory, Occupational Health Branch Programs and Activities, Occupational Health Branch Publications & Videos, What's New at the Occupational Health Branch, Work-Related Valley Fever (Coccidioidomycosis), Occupational Health Watch April 2017: Spotlight on Skylight Falls for Workers Memorial Day, Occupational Health Watch July 2016: August Is Valley Fever Awareness Month, Substance Addiction and Prevention Branch, Division of Food, Drug, and Cannabis Safety, FDLB Chemistry and Microbiology Client List, Abused Substances Analysis Section (ASAS), Division of Radiation Safety and Environmental Management, Radiologic Technology Certification Committee, Certificates, Licenses, Permits and Registrations, Genetic Disease Screening Program Publications, GDSP Notice Of Information And Privacy Practices, Maternal, Child and Adolescent Health Division, AFLP RFA 2020: Public Notice of Intent to Award, AFLP Request for Applications #20-10014, Addendum #9, AFLP Request for Applications #20-10014, Addendum #10, AFLP RFA 2020: Final Announcement of Awards, Program Consultants and Contract Managers, Where We Are: Local BIH Sites and Coordinators, Guidelines and Resources for Community Partners, Breastfeeding Model Hospital Policy Recommendations, Lactation Accommodation: For Child Care Providers, Lactation Accommodation: For Community Partners, In-Hospital Breastfeeding Initiation Data, Lactation Accommodation Laws for Workplace, Jails and School, California Personal Responsibility Education Program, CA PREP Questions and Answers for 2018 RFA, CA PREP Program Consultants and Contract Managers, Human Stem Cell Research Advisory Committee, I&E Program Consultants and Contract Managers, Local Maternal, Child and Adolescent Health, Emergency Preparedness: Infant and Young Child Feeding, Healthy Weight for Healthy Birth and Beyond, Multiple Factors Affect Birthing Parents’ Weight, Regional Perinatal Programs of California, Where We Are: Local RPPC Sites and Coordinators, Resources for Hospital and Health Care Providers, California Maternal Quality Improvement Toolkit, CMQCC Improving Health Care Response to Maternal Venous Thromboembolism, CMQCC Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum, Sudden Infant Death Syndrome (SIDS) Program, Title V Maternal and Child Health Block Grant, MonitoringAdherenceToHCPracticesThatPreventInfection, Healthcare Personnel Influenza Vaccination Reporting In CA Hospitals, CA Campaign To Prevent BSI in Hemodialysis Patients, Central Line-associated Blood Stream Infection (CLABSI), Methicillin-Resistant Staphylococcus aureus Bloodstream Infection (MRSA BSI), Vancomycin-resistant Enterococci Bloodstream Infection (VRE BSI), Center for Health Statistics and Informatics, California Marriage License, Registration and Ceremony Information, Vital Records Obtaining Certified Copies of Death Records, Obtaining Vital Records From County Offices, Vital Records Issuance and Preservation Branch, California Marriage License General Information, HIV/AIDS ADAP Health Insurance Premium Payment Assistance, HIV/AIDS ADAP Medicare Part D Premium Payment Assistance, About the Viral and Rickettsial Disease Lab, Communicable Disease Emergency Response Program, DCDC Information for Local Health Departments, Sexually Transmitted Diseases Control Branch, VRDL Guidelines for Specimen Collection and Submission for Pathologic Testing, Office of Binational Border Health Publications, Office of Binational Border Health Advisory Group, About the Office of Binational Border Health, Contact the Office of Binational Border Health, Quarterly Binational Epidemiology Meetings, Border Infectious Disease Surveillance - Coccidioidomycosis, Border Infectious Disease Surveillance - Queso Fresco, Border Infectious Disease Surveillance - Mosquito-borne-diseases, Border Infetious Disease Surveillance - Rocky Mountain Spotted Fever, Border Infectious Disease Surveillance - Influenza and Other Respiratory Infections, Emergency and Evacuation Planning Guide for Schools, Tips for Communicating with Students During an Emergency, Know When and How to Shelter-in-Place for Schools, How to Help Students Cope and Deal with Stress, Pandemic Flu Preparedness For Schools - Home, Fusion Center (Strategic Development and External Relations), Office of Health Equity - Health Equity Policy & Planning Unit, Climate Change and Health Equity Program (CCHEP), Office of Health Equity Advisory Committee, Health Research and Statistics Unit (HRSU), CDPH Climate Change and Health Profile Reports, CDPH Climate Change and Health Vulnerability Indicators, Office of Legislative and Governmental Affairs, CDPH Lifts Rock Crab Health Advisory in Portions of San Mateo County - South of Pillar Point, CDPH Launches Mobile Website for WIC Participants, CDPH Reports Widespread Flu Activity that is More Severe than Last Year, CDPH Fines San Francisco County Facility in Death of Resident, CDPH Fines Los Angeles County Facility in Death of Resident, Let’s Get Healthy California Announces Local Innovations to Improve California’s Health, Dungeness Crab Health Advisory Lifted for Remainder of California Coast, Dungeness Crab Health Advisory Lifted in Portions of Mendocino County – South of Ten Mile River, CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from San Luis Obispo County, Dungeness Crab Health Advisory Lifted in Portions of Sonoma, Mendocino, Humboldt Counties, CDPH Releases Reports on Healthcare-Associated Infections, Influenza Vaccination Rates Among Healthcare Personnel, CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from Monterey County, CDPH Awarded Grant to Expand Child Safety-Seat Use, CDPH Awarded Grant to Study Motor-Vehicle Crash Injuries, Holiday Travelers Reminded to Take Precautions to Prevent Zika, Local Transmission Confirmed in Ensenada, Mexico, Office of Quality Performance and Accreditation, Meet the Former Interns - Yesenia Posadas, Office of the State Public Health Laboratory Director, California Laboratory Animal Use Approval Program, Job Opportunities - Laboratory Field Services, Complaints Program - Laboratory Field Services, Clinical Laboratory Technology Advisory Committee (CLTAC), Clinical Laboratory Scientist Trainee License, Clinical Chemist Scientist Trainee License, Clinical Cytogeneticist Scientist Trainee License, Clinical Genetic Molecular Biologist Scientist Trainee License, Clinical Hematologist Scientist Trainee License, Clinical Histocompatibility Scientist Trainee License, Clinical Immunohematologist Scientist Trainee License, Clinical Microbiologist Scientist Trainee License, Clinical Toxicologist Scientist Trainee License, Clinical Laboratory Professional Licensing, Renewal of Clinical Laboratory Personnel Licenses & Certificates, Personnel License Changes & Duplicate Requests, Statement of CDPH HIPAA Covered Entity Status, DPH-16-015E Newborn Screening Fee Increase, DPH-16-016E Prenatal (Multiple Marker) Screening Program, DPH-05-012 Forensic Alcohol Testing Laboratories, DPH-11-004 Pre-Kindergarten and School Immunization Requirements, DPH-17-004 Medical Cannabis Manufacturing, EXEMPT-11-011 Tissue Donors HIV Sperm Washing, Forms: Licensing and Certification Program, en Training videos are available for the following forms: Licensure & Certification Application Form (HS 200) Applicant Individual Information (HS 215A) to Default, Methicillin-Resistant Staphylococcus Aureus Bloodstream Infection, Registered Environmental Health Specialist, Mosquito Disease Surveillance and Control, California Health Facilities Information Database, Chronic Disease Surveillance and Research, Medical Marijuana Identification Card Program, Office of State Public Health Laboratory Director, Centers for Disease Control and Prevention. Enter the center’s license capacity. Street Address City, State, Zip Code. Last updated: 1/4/2021 1. A.8.a. It looks like your browser does not have JavaScript enabled. Provider or legal representative means the Board Chairperson, President, or Managing Employee. We recommend that you obtain a Business License Compliance Package (BLCP)®. Proposed facility bed capacity 9. Reset Is construction required No If yes submit copy of OSHPD form see instructions on page 6 If yes date construction to begin HS 200 02/08 B. Application Form Guidance - CDPH Licensing and Certification (L&C) launched several online training videos to provide guidance to providers completing application packets for facility licensing. Español, - Cdph 530. HS 200 Application for Facility License HS 215A Applicant Information HS 308 Administrative Responsibility ... HS 609 Bed or Service Request CDPH 241–267 Supplemental Service Applications CDPH 268 Application for Supplemental Services Approval CDPH 709 Client Accommodations Analysis DHCS 9098 Medi-Cal Institutional Providers Agreement The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. BCIA 8016 Sample FIU (PDF) - Request for Live Scan Service, CDPH 171 (PDF) - 40 Hour Home Health Aide (HHA) Training Program Application, CDPH 171 A (PDF) - 40 Hour Home Health Aide (HHA) Training Program Current Curriculum, CDPH 171 B (PDF) - 40 Hour Home Health Aide (HHA) Training Program Faculty Application, CDPH 183 (PDF) - Home Health Aide (HHA) Certification List, CDPH 191 (PDF) - 120 Hour Home Health Aide (HHA) Training Program Application, CDPH 191 A (PDF) - 120 Hour Home Health Aide (HHA) Training Program Current Curriculum, CDPH 191 B (PDF) - 120 Hour Home Health Aide (HHA) Training Program Faculty Application, CDPH 192 (PDF) - Application for Initial/Renewal Approval as a Continuing Education (CE) Provider, CDPH 192 B (PDF) - Application for Initial/Renewal Approval as an Online Continuing Education Provider, CDPH 193 (PDF) - Facility/School Contact Information, CDPH 241 (PDF) - Application for Cardiovascular Surgery Service, CDPH 242 (PDF) - Application for Chronic Dialysis Service, CDPH 243 (PDF) - Application for Dental Service, CDPH 245 (PDF) - Application for Nuclear Medicine Service, CDPH 246 (PDF) - Application for Outpatient Service, CDPH 247 (PDF) - Application for Pediatric Service, CDPH 248 (PDF) - Application for Perinatal Unit, CDPH 249 (PDF) - Application for Podiatric Service, CDPH 250 (PDF) - Application for Psychiatric Unit, CDPH 251 (PDF) - Application for Radiation Therapy Service, CDPH 252 (PDF) - Application for Renal Transplant Center, CDPH 253 (PDF) - Application for Respiratory Care Service, CDPH 255 (PDF) - Application for Social Service, CDPH 256 (PDF) - Application for Standby Emergency Medical Service, Physician on Call, CDPH 257 (PDF) - Application for Basic Emergency Medical Service, Physician on Duty, CDPH 258 (PDF) - Application for Comprehensive Emergency Medical Service, CDPH 259 (PDF) - Application for Rehabilitation Center, CDPH 260 (PDF) - Application for Occupational Therapy Service, CDPH 261 (PDF) - Application for Physical Therapy Service, CDPH 262 (PDF) - Application for Speech Pathology and/or Audiology Service, CDPH 263 (PDF) - Application for Acute Respiratory Care Service, CDPH 264 (PDF) - Application for Burn Center, CDPH 265 (PDF) - Application for Coronary Care Service, CDPH 266 (PDF) - Application for Intensive Care Newborn Nursery Service, CDPH 267 (PDF) - Application for Intensive Care Service, CDPH 268 (PDF) - Application for Supplemental Services Approval, CDPH 270 (PDF) - Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, CDPH 272 (PDF) - Elective Percutaneous Coronary Intervention (PCI) Program Application, CDPH E276 (PDF) - Online Nurse Assistant Training Program Application, CDPH 276 A (PDF) - Nurse Assistant Training Program Skills Check List Sample, CDPH E276 A (PDF) - Online Nurse Assistant Training Program Skills Checklist, CDPH 276 B (PDF) - Daily Nurse Assistant Training Program Schedule, CDPH E276 B (PDF) - Online Nurse Assistant Training Program Daily Clinical Schedule, CDPH 276 B Sample (PDF) -Daily Nurse Assistant Training Program Schedule Sample, CDPH 276 C (PDF) - Nurse Assistant Certification Training Program Individual Student Record, CDPH E276 C (PDF) - Online Nurse Assistant Certification Training Program Individual Student Record, CDPH 276 D (PDF) - Disclosure of Ownership and Control Interest Statement, CDPH 276 E (PDF) - Nurse Assistant Training Program and/or Home Health Aide Program Clinical Site Agreement, CDPH E276 E (PDF) - Online Nurse Assistant Training Program Clinical Training Site Agreement, CDPH 276 F (PDF) - Skilled Nursing Facility (SNF) Nurse Assistant Certification Training Program Application, CDPH 276 P (PDF) - Instructions for Development and Implementation of Policies and Procedures by Nurse Assistant Training Program Applicants, CDPH E276 P (PDF) - Online Nurse Assistant Training Program Sample Policies and Procedures, CDPH 276 S (PDF) - School Nurse Assistant Certification Training Program Application, CDPH 278 A (PDF) - Nurse Assistant Orientation Program Content, CDPH 278 B (PDF) - In-Service Training Program, CDPH 278 C (PDF) - Facility Declaration of Participation in Approved Training Programs, CDPH E278 C (PDF) - Facility Declaration of Participation in Approved Online Training Program, CDPH 278 SC (PDF) - Option 2 Nurse Assistant Pre-Certification Training Contract, CDPH E278 SC (PDF) - Option 2 Online Nurse Assistant Training Program Sample Contract, CDPH 279 (PDF) - Instructor or Director of Staff Development (DSD) Application, CDPH E279 (PDF) - Online Nurse Assistant Training Program Instructor or Director of Staff Development Application, CDPH 283 A (PDF) - Certified Nurse Assistant (CNA), Home Health Aide (HHA), In-Service Training/Continuing Education Units (CEUs), CDPH 283 B (PDF) - Certified Nurse Assistant (CNA) Initial Application, CDPH 283 C (PDF) - Certified Nurse Assistant (CNA) and/or Home Health Aide (HHA) Renewal Application, CDPH 283 D (PDF) - Home Health Aide (HHA) Initial Application, CDPH 283 F (PDF) - Certified Hemodialysis Technician (CHT) Initial Application, CDPH 283 G (PDF) - Certified Hemodialysis Technician (CHT) Renewal Application, CDPH 283 I (PDF) - Transmittal for Criminal Background Clearance, CDPH E299 (PDF) - Online Nurse Assistant Training Program Curriculum Vendor Application, CDPH 310 (PDF) - MDS 3.0 Section S California, CDPH 318 (PDF) - CNA/HHA/CHT Report of Misconduct, CDPH 322 (PDF) - Transmittal Application for Criminal Record Clearance, CDPH 325 (PDF) - Criminal Record Clearance Submissions, CDPH 327 (PDF) - California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, CDPH 391 (PDF) - Hemodialysis Technician/Patient Care Technician Training Program Application, CDPH 414 (PDF) - Application for Health Facility/Agency Change of Location, CDPH 501 (PDF) - Administrator in Training (AIT) Evaluation Report, CDPH 502 (PDF) - Application for AIT Program, CDPH 502 A (PDF) - Application for Educational Waiver for AIT Program, CDPH 503 (PDF) - Application for Nursing Home Administrator State Examination, CDPH 505 (PDF) - Application for Nursing Home Administrator National Examination, CDPH 506 (PDF) - Application for Nursing Home Administrator License, CDPH 507 (PDF) - Modification of Administrator in Training Hours Request, CDPH 508 (PDF) - Application to Become a Provider of Continuing Education, CDPH 509 (PDF) - Continuing Education Courses Completed for Active License Renewal, CDPH 510 (PDF) - Declaration and Request for Replacement License, CDPH 511 (PDF) - Instructor Application for C.E. 916 ) 552-8785 CDPH 246 form program hours ) FAX: ( 916 ) 327-2445 FAX: ( ). 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