• License number
  
• Facility name and address
• Facility ID number (if known)
  
• Brief description of request
• Include end date of prior person in the role and start date for the current person in the role
  
• ​Cont​act information (name, title, phone number, and e-mail address)
  
• Emergency Contact Information (name, email, alternate email. phone, fax, and phone number that will receive text messages). The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information: CAHAN​ (https://www.calhospitalprepare.org/cahan)
  
• Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address)
  
• Signature

[Title 22 California Code of Regulations (CCR) section 78205(a)(2) and 78415(a)]​

• This form must be completed and signed for the administrator of the facility

• Section A — List facility name and business address. Select facility type and type of application
• Section B – List applicant’s legal name, nature of involvement to the facility, date of birth, driver’s license or state-issued identification number and expiration date, social security number
• Section E — Submit ten years of employment history, indicating employer name and address, the start and end dates of employment, job title. The applicant may submit a resume in lieu of this section. The resume must contain all required information requested in section E
• Be sure to include every facility where the applicant is a currently an administrator
• Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)
  
• Applicant Release — Be sure that applicant signs and dates this section, print name and title

Resume

[22 CCR section 78205(a)(2) and 78415] 

A resume is required for the administrator

​Criminal Record Clearance Submissions

[Health and Safety Code (HSC) section 1575.7]​

• Submit for the administrator
  

[HSC section 1575.7]

Mail this form to the address indicated on the form only for the new administrator​

Note: In addition, submit copy of this form to CDPH Criminal Background Section. Centralized Applications Branch may also request a copy of this form.