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This form is used to request Live Scan service for certification as a Certified Nurse Assistant (CNA) or Home Health Aide (HHA) in California.
Applicants must provide personal information including their Social Security Number, date of birth, and physical characteristics such as height and weight.
The California Department of Public Health (CDPH) is the agency authorized to receive criminal record information related to the certification process.
Applicants are advised to input their Social Security Number accurately to ensure timely processing of their certification results.
The form includes sections for Live Scan transaction details, including operator name, date, and amount collected or billed.
The form has multiple copies: one for the Live Scan operator, one for the applicant, and additional copies if needed for the requesting agency.
If an application is a re-submission, applicants must provide proof of rejection along with their original ATI number.
