Contra Costa College
Certified Nursing Assistant/Home Health AIDE
Please Note: Applications for Admission to the
CNA - HHA Program are accepted in the Nursing Office between
May 15, 2013 and August 1, 2013
(FYI: the campus is closed on Fridays in June and July)
All Classes for fall 2013 begin August 16, 2013
Nursing 202-CNA/HHA 1st meeting=08/20/13
Dear CNA-HHA Applicant:
Thank you for your interest in the CNA - HHA Program at Contra Costa College.
You must be enrolled in Contra Costa College to apply for the CNA - HHA Program.
You can submit a college application via “on-line” www.contracosta.edu or in paper
form at Admissions & Records in the Student Services Center. Class registration is on
a 1st come/1st served basis at Admissions & Records for those students approved
by the Nursing Department to enroll in the CNA – HHA Program. There are 6 steps
to the CNA - HHA application process (forms are included).
Step 1: Submit the following to the Nursing Department (HS 103) for the CNA HHA program.
□ CNA – HHA Admissions Application form
o Submit to the Nursing Department by August 1, 2013. This is separate
from the College Application
 (CNA – HHA FORM A)
o Assessment tests for Reading & Writing and Math must be obtained from
the College Assessment Center, Student Services Center room 104 (SSC
104) OR equivalent English and Math Class.
o Submit assessment testing results with application to the Nursing Dept. by
August 1, 2013.)
 (CNA – HHA FORM A)
□ Confidential Application for Clinical Practice
o Submit to the Nursing Department by August 1, 2013
 (CNA–HHA Form B)
Step 2: Complete a CPR course -- American Heart Assn.: “CPR for Healthcare
Provider”
□ Course can be completed through a private CPR provider or through Contra
Costa College’s fee based class. This is a pre-requisite for CNA – HHA
approval to enroll in the CNA – HHA Program.
□ A copy of your certification card will be required for your file in the Nursing Dept.
Certification must be current throughout the class.
Step 3: Nursing Department Review of File.
□ Bring all completed items in Step 1 and Step 2 to the Nursing Department
(HS103) in order for your file to be reviewed and your status as an eligible
student in the CNA – HHA Program to be communicated to you.
o The Nursing Department will communicate your eligibility for enrollment in
the CNA – HHA Program or steps required to become eligible to enroll in
the CNA – HHA program.
IMPORTANT NOTE: Step 1 and Step 2 and Step 3 must be completed before
registering in the CNA - HHA program.
Step 4: Admissions & Records
□ If you are deemed eligible to enroll in the CNA – HHA program by the Nursing
Department you will be instructed to go to Admissions and Records.
o At Admissions & records you will enroll in Nursing 202, and English 142A
& English 102 at Admissions & Records.

Bring your CPR certification card to Admissions & Records to
register.
□ If you require additional coursework or evaluation for eligibility the Nursing
Department will provide you with this information and suggest the next steps for
you to take.
Step 5: Medical Exam (Students accepted into the CNA – HHA Program)
□ CNA – HHA Medical Evaluation form (completed form due by August 16,
2013: CNA – HHA Form C)
SUGGESTIONS FOR PHYSICAL EXAM:
o Private Physician
o Brookside Clinic 510-215-9092
o Richmond Outpatient Clinic 1-800-495-8885
IMPORTANT NOTE: The Physical Exam form must be completed and turned in to the
Nursing Secretary by August 16, 2013. If you do not meet the deadline you will not be
able to participate in the class, SO PLAN AHEAD! You may not take class time to
complete this requirement. It is considered an absence.
Step 6: Live Scan Fingerprinting (Students accepted into the CNA – HHA
Program)
FINGERPRINTING: The Department of Health Services requires you to have a background
check by the Department of Justice. To achieve this you must complete the LiveScan
fingerprinting process. You will be instructed on the fingerprinting process when you are
enrolled and attending the CNA – HHA Program. Fingerprinting will take place with CCC
Campus Police at no charge to the student. Forms will be provided by the Nursing
Office.
** ALL APPLICANTS BACKGROUNDS MUST BE INVESTIGATED BY THE DEPARTMENT OF JUSTICE. THIS
INVESTIGATION IS SPECIFIC TO THE CNA/HHA APPLICATION. PREVIOUS INVESTIGATIONS DO NOT APPLY.
**IF YOU HAVE BEEN CONVICTED BY ANY COURT OF A CRIME (OTHER THAN A MINOR TRAFFIC VIOLATION), THE
DEPARTMENT OF HEALTH SERVICES REQUIRES A CLEARANCE BEFORE ENROLLING IN A NURSE AIDE OR HOME
HEALTH AIDE COURSE.
IF THIS PERTAINS TO YOU, TO OBTAIN A CLEARANCE YOU MUST CONTACT THE DEPARTMENT OF HEALTH SERVICES,
DIVISION OF LICENSING AND CERTIFICATION, NURSE ASSISTANT CERTIFICATION SECTION AT (916) 327-2445, OR
WRITE TO NACS ENFORCEMENT CONSULTANT, DEPARTMENT OF HEALTH SERVICES, P.O. BOX 942732,
SACRAMENTO, CA 94234-7320, ASKING IF YOU WILL BE ABLE TO BE CERTIFIED CONSIDERING YOUR CONVICTION.
FLAG YOUR LETTER “CONFIDENTIAL.” ALLOW APPROXIMATELY 30 DAYS FOR TURN AROUND.
Disqualifying Penal Code Sections
If they have been convicted of any of the penal codes listed, CNA/HHA
applicants will be automatically denied certification or ICF/DD, DDH, or DDN
applicants will be denied employment.
All CNA/HHA applicants should review this list carefully to avoid wasting
their time, effort and money by training, testing and submission of
fingerprints since they cannot receive the required criminal background
clearance if they have been convicted of any of these violations.
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))
Section
273.5 Willful infliction of corporal injury (Includes (a)-(h))
285 Incest
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
Certification of applicants with convictions on this list MAY be reconsidered by ATCS
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 by ATCS.
ATCS 98-4 (4/02)
http://www.cdph.ca.gov/certlic/occupations/Documents/ATCS%2098-4.pdf
Students accepted and then enrolled into the CNA – HHA Program will also receive
instructions on completing the California Department of Public Health Application Form
CDPH 283B within the first week of instruction.
[CNA – HHA Form A]
Contra Costa College Certified Nursing Assistant – Home Health Aide Program
(Return to the Nursing Dept., HS 103)
APPLICATION
Please fill-out
Name ____________________________________________________________________
(LAST)
(FIRST)
(MIDDLE)
(PREVIOUS)
Address: _________________________________________________________________
(STREET)
(CITY)
(STATE) (ZIP)
Student ID# or SSN # ____________________________
Day Phone: (
) _____________ Evening (
Birth date ____/_____/______
) ____________ Cell (
) _____________
E-mail address: ___________________________________________________________
Emergency Contact person:
(Name)
_____________________________________________________
(Telephone #)
(Relationship)
Prerequisite Requirements CNA – HHA Program
ESL Students

ESL placement at level three or completion of ESL 146 or the equivalent with a score of “C” or better.
DSPS Students

Completion of English 082 or 084 with a grade of “C” or better.
College Reading Assessment Score Range

Score of 34 or completion of English 92 with a grade of “C” or better.
College Writing Assessment Score Range

Score of 25 or completion of English 92 with a grade of “C” or better.
College Pre-Algebra Assessment Test

Score of 25 or completion of Math 101 with grade of “C” or better.
Cardio Pulmonary Resuscitation (CPR)

CPR certification for the Healthcare Provider.
I have completed the Reading, Writing and Math Assessment tests
-Min. scores: Reading=34, Writing=25, Math=25
I am enrolled or have successfully completed English 92.
I have completed ESL 142A or have a placement level of 3.
I have completed ENGL 81, ENGL 82, or ENGL 83
I have complete Math 101 or higher
Signature: ______________________________________________________
(date)
For Office Use Only
HS 283B Application Received
Completed LiveScan form
CPR for HealthCare Provider
Assessment tests
[CNA – HHA Form B]
LAVA Division
Nursing Department
Certified Nurse Assistant – Home Health Aide Program
Confidential Application for Clinical Practice
(Return to the Nursing Dept. Office )
(updated 03-12-10)
Applicant information:
Last Name
First Name
MI
Maiden
Address
City
State
Zip
Email
Phone (day)
Phone (eve)
Phone (cell)
Criminal Public Record Check
Yes
Have you ever been convicted ¹ of any crime ² under you current name or
No
any other name?
Yes
Do you have a criminal case now pending?
No
Yes
Clinical assignments are in health facilities that allow you access to drugs
No
and medications. Have you ever been arrested for an offense involving
controlled substances? (Cal Labor Code 432.7f, Cal Health and Safety
Code 11590)
Yes
Clinical assignments are in health facilities that allow you regular access to
No
patients. Have you ever been arrested for a sex offense for which
registration as a sex offender would be required upon conviction? (Cal
Labor Cole 432.7f, Penal Code 290)
Yes
Do you understand that a background check; reference verification; and
No
drug screening, is a part of the enrollment decision making process, and if
you are invited to participate in the program that you consent to complete a
background investigation.
Applicant Statement
I certify that all statements made on this form are true and correct. I understand that
any misrepresentation or falsification of material facts in this application may be cause
for immediate disqualification and removal from program.
Signature of Applicant: ___________________________________
Date: _________________
[CNA – HHA Form C]
CONTRA COSTA COLLEGE
Certified Nursing Assistant/ Home Health Aide Program
Medical Evaluation Form
STUDENT NAME_____________________________________________ MALE
Last
First

FEMALE 
Middle
ADDRESS____________________________________________________________________
Street
City
State
Zip
PHONE __________________ SS#/Student ID_______________ BIRTH DATE ______________
1. Required Titers: ALL LAB RESULTS MUST BE ATTACHED (Negative results require vaccinations)
Pos =  Neg. = __ )
 Hepatitis B Date of Test ___ __ or Vaccination Dates #1:_____ #2: _______#3: ______
 Influenza vaccination for current flu season Date of vaccination:______________
__
 TB
Date of Test _____________
NOTE: If Positive TB, [, attach results of base-line X-ray (should not be repeated any more
often than five years) and M.D.’s clearance for clinical attendance. [ __ = Neg.]
2. Laboratory Finding: ALL LAB RESULTS MUST BE ATTACHED
CBC & Differential

UA routine 
3. Is there any significant medical history:

Yes
No
If yes, explain _________________
4. Is there any health condition that would create a hazard to this student, fellow employees, or
patients or visitors:
Yes

No

If yes, explain
____________________
Does your examination of the student reveal any limitations in the following:
SPINE: Yes  No 
LIFTING: Yes  No 
BENDING: Yes  No 
No Limitations of any type
Please feel free to use the back of this form if you need to report additional information.
Physician’s Report of Health Status
1.
2.
3.
4.
5.
6.
7.
8.
Blood Pressure________________________
Heart _______________________________
Lungs _______________________________
Mouth and Teeth ______________________
Throat ______________________________
Skin ________________________________
Eyes Vision Test Date __________________
Vision with Glasses
9. Hernia____________________________
10. Orthopedic ________________________
11. Hearing Test Date __________________
Findings: _________________________
12. Height ___________________________
13. Weight ___________________________
Findings: R eye ___________ L eye ___________
Findings: R eye ___________ L eye ___________
Examining Physician or Nurse Practitioner:
Based upon today’s exam and the disclosed health history, this student does not have any health condition
that would create a hazard to self or others, or limit their ability to provide health care.
Signature ________________________________
Date ____________________________________
Print Name ______________________________
Phone No_______________________________
CCC CNA-HHA Uniform Information
Dear Nursing Student:
The approved nursing uniforms for the Contra Costa College CNA-HHA Program are available
from Life Uniform. We are very pleased to introduce you to our local retailer of Life Uniform
and to the Manager, Felicia Freeman.
The store is located at:
Life Uniform
Pinole Vista Shopping Center (near Food Maxx)
1354 Fitzgerald Drive
Pinole, CA 94564
(510) 223-0768
Hours: M-F 10 am-8 pm
Sat. 10 am-6 pm
Sun. 12 pm-5 pm
You may shop at Life Uniform any day to purchase your approved uniforms. Tell the sales
people that you are from Contra Costa College
CNA-HHA Program.
The uniform is a WHITE TOP WITH LIGHT BLUE PANTS. The uniform store has a list of approved
uniform styles. Felicia has assured us that a large supply of all styles is available. She has
ordered various sizes and there should be sufficient supply on hand to accommodate all student
needs. White uniform jackets may be worn in most clinical areas and are available at Life
Uniform.
Students should plan to purchase two (2) uniform sets to provide a clean set for each clinical
day. School patches can be purchased at the CCC Bookstore. They are to be sewn onto the left
shoulder sleeve of the uniform and the sweater or outer jacket. A CNA-HHA skills lab kit is also
available in the college bookstore. Your student I.D. obtained at the Student Union will serve as
your name badge. Other items you will need to purchase include a watch with a second hand.
All-white, leather, closed heel, professional shoes are required and women’s styles are also
available for purchase at Life Uniform.
Contra Costa College
L.A.V.A. Division
Nursing Department
Certified Nursing Assistant – Home Health Aide Program
Supplies and Equipment you will need for this class:
Textbooks:




“Mosby’s Textbook for Nursing Assistants, 8th edition”, Sorrentino
“The Home Health Aide Handbook, 2nd edition”, Fuzy
“Nursing 202 Syllabus”, Certified Nursing Assistant/Home Health Aide Course
Syllabus (bookstore)
“Nursing 202 Home Health Aide Addendum” (bookstore)
Supplies:











Three ring binder
Binder paper
#2 pencil
Black pen
3x5 cards (for vocabulary study)
Watch with sweep second hand
1 small spiral note pad (should fit in uniform pocket)
Supply kit: (contains: 1 sphygmomanometer, 1 stethoscope, 1 gait belt, mask,
gloves. May be purchased in the College Book Store.
2 Contra Costa College patches for your uniform(purchase in college book
store) These are placed on the left shoulder sleeve of your uniform top
2 uniforms White top, Light blue pants (as defined by CCC instructors) with CCC
patch attached to left shoulder.
1 pair of ALL white leather/leatherette fully enclosed nursing or sport shoes
(should be worn with solid white socks or white or beige nylons or knee-highs).
If you have any questions, contact Diana Hall,
Administrative Secretary for the Nursing Department at:
dhall@contracosta.edu or 510-235-7800 ext. 4267.
Revised 1/6/04, 11/22/04, 6/21/05, 6/10/07, 4/26/08, 12/11, 10/12, 02/13