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Home Care Aide Certification Application PacketContents:1. 675-002. Contents List/SSN Information/Mailing Information. 1 page2. 675-003. Certification Requirements and ApplicationInstructions Checklist. 4 pages3. 675-005. Home Care Aide Certification Application. 7 pages4. 675-006. Employment Verification . 1 page5. RCW/WAC and Online Website Links. 1 pageImportant Social Security Number Information:You are required by state and federal law to provide a social security number with yourapplication. If you do not have a social security number at the time you send in thisapplication, please read, complete, and return this form with your application.A U.S. Individual Taxpayer Identification Number (ITIN) or a Canadian Social InsuranceNumber (SIN) cannot be substituted.In order to process your request:Mail your application with initialdocumentation and your checkor money order payable to:Send other documents not sent withinitial application to:Department of HealthHome Care Aide CredentialingP.O. Box 1099Olympia, WA 98507-1099Home Care Aide CredentialingP.O. Box 47877Olympia, WA 98504-7877Contact us:360-236-2700Home Care Aide Credentialing360-236-4700Customer Service CenterDOH 675-002 September 2020

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Requirements for Home Care Aide Certification1.Submit the completed home care aide application to the Department of Health,including the Employment Verification form.2.Complete Department of Social and Health Services (DSHS) fingerprint-basedbackground check.3.Complete a 75-hour basic training course approved by DSHS before taking thehome care aide state certification examination.4.Pass the home care aide knowledge and skills certification examinations.You may provide care without a credential after you complete the following: Submit completed application and fees within 14 days of your date of hire; Complete the training required by RCW 74.39A.074(1)(d)(i)(A) and (B).You must complete all training within 120 calendar days of the date of hire. The deadlineto become certified as a home care aide is 200 days from date of hire. If you do not meetthese time frames, you are no longer eligible to provide care. You must stop working untilyou receive a home care aide certification.Application Instructions ChecklistYou must hand write in English all information clearly in ink. It is your responsibility tosubmit the required forms to the department.FF Application and Examination Fees. Complete and submit the original applicationwith fees. Application fees are non-refundable.FF Examination and payment selection: Select state pay if your fees are being paid for by theSEIU Training Partnership. Select self pay if you or your employer are paying your fees. Send your paymentwith the completed application.FF Fingerprint-based Background Inquiry ID/OCA#: Complete a DSHS fingerprintbased background check, working with your employer or case manager. Thedepartment will only accept the most recent fingerprint-based background inquiry ID/OCA#. If you do not have an ID/OCA#, submit the application without it and contactus when you receive it.FF Provisional Certificate: Select if you are applying for a provisional certificateavailable to home care aides limited in their ability to read, write, or speak English.See RCW 18.88B.021. The provisional certification may only be issued once andis valid for an additional 60 days, for a total of 260 days from the hire date to meetcertification requirement.DOH 675-003 September 2020Page 1 of 4

FF Select if the following applies:Spouse or Registered Domestic Partner of Military PersonnelFF 1. Demographic Information:Social Security Number: You must list your social security number on yourapplication. If you do not have one, complete and return this form.Legal Name: List your full name: first, middle, and last.Definition of legal name: “Legal name” is the name appearing on your officialcertificate of birth or, if your name has changed since birth, on an official marriagecertificate or an order by a court. The court must have the legal authority to changeyour name. We may ask you to prove your legal name. If you use any name otherthan your legal name on this form, your application may be denied.Birth date: Provide the month, day, and year you were born.Address: List the address we should use to send you any information about yourcredential. Be sure to include the city, state, zip code, county, and country. This willbe your permanent address with the Department of Health until you notify us of achange. See WAC 246-12-310.Phone, Fax, and Cell Numbers: Enter your phone, fax, and cell numbers, if youhave them.Email Address for Test Date (Required): Enter your email address for examination.The examination company will send test date information to this email address. Anemail address is required by the examination company.Personal Email Address (Optional): Enter your personal email address.Communication sent from the department will be sent to this address.Employer Email (Optional): Enter your employer’s email address. Your employer willreceive communication sent to you by the department.Other Name(s): List any other names you are or have been known by. If you have aname change after obtaining a credential, you must notify the department in writing.You must include legal proof of this change. See WAC 246-12-300.FF 2: Personal Data Questions:All applicants must answer the same personal data questions on the application. Theyare focused on your fitness to practice the essential skills of this profession.If you answer “yes” to any questions in this section, you must provide a complete andaccurate explanation. You must submit the appropriate documentation as noted in thepersonal data questions. If you do not provide this, your application is incomplete andit will not be considered. Question 5 refers to misdemeanors, gross misdemeanors and felonies. You donot have to answer “yes” if you have been cited for traffic infractions. You can getcopies of your court records through the county courthouse where the conviction,plea, deferred sentence, or suspended sentence was entered. Another jurisdiction means any other country, state, federal territory, or militaryauthority in which convictions may have occurred.DOH 675-003 September 2020Page 2 of 4

FF 3: Type of Services Provided: Check all that apply: Long-term care workers who must become certified home care aides. Individuals who are not required to be a home care aide, but choose to apply.FF 4: Other License, Certification, or Registration:List all credentials you have held since last being credentialed in WashingtonState. List in date order, most recent to later. Include your last active credential inWashington State. Attach additional completed pages if you need additional space.FF 5: Examination:You must complete this section to be scheduled for the required examinations. Check “Yes” if you are requesting a testing accommodation OR a one on oneinterpreter in a language that is not listed on page six of the application. Print and complete the testing accommodations request packet (only page three ifrequesting an individual interpreter) and submit directly to Prometric at: Prometric,Attn: Washington Home Care Aide Program, 7941 Corporate Dr., Nottingham, MD21236.Note: Reasonable testing accommodations are available to candidates withdocumented disabilities recognized under the Americans with Disabilities Act(ADA).Thirty days advance notice is required for all special testing. You will be notifiedwhether your request is approved before testing is scheduled. There is noadditional charge for these accommodations.Once we have received notification that your training has been completed, theexamination fee has been paid, and all documents have been received by thedepartment; we will notify the examination company, Prometric, that you areauthorized to test and email an examination authorization letter to you.Prometric will email you an admission to test letter with the date, time, and place ofthe examination. Once you have taken your examination, Prometric will send thedepartment your examination results.Examination retakes are scheduled directly by Prometric. See the Prometric websitefor more information.FF 6: Applicant’s Attestation:You must sign and date this for us to process the application.DOH 675-003 September 2020Page 3 of 4

Additional Documents Required with the Application:FF Employment Verification Form:Have your employer complete this form.Applicants that are exempt from training and certification require an additionalemployment verification form from the employer they worked for between January 1,2011 and January 6, 2012.FF Out-of-State Credential Verification Form:If you worked as a healthcare provider in another state or jurisdiction, submit a copyof the verification form to each state you hold or have held a healthcare license,certification, or registration. The state will complete its portion of the form and mail itdirectly to us.For Spouses and Registered Domestic Partners of MilitaryPersonnel Being Transferred or Stationed in Washington:Under state law, if you are the spouse or state registered domestic partner of aservicemember of any branch of the U.S. Military, to include Guard or Reserve, and areapplying for a healthcare professional credential in this state, you may be eligible to have theprocessing of your application expedited to receive your credential more quickly.Documents to submit with your application should include the following: A copy of your spouse’s or registered domestic partner’s military transfer orders toWashington State. One of the following:-- A copy of your marriage certificate to show proof of marriage; or-- A copy of a state’s declaration or registration showing you are in a stateregistered domestic partnership with a member of the U.S. military.DOH 675-003 September 2020Page 4 of 4

DateStampHereHome Care Aide CredentialingP.O. Box 1099Olympia, WA 98507-1099Revenue 0299100001Home Care Aide Certification ApplicationFingerprint-based background inquiry ID/OCA #:If you do not have a fingerprint-based background OCA #, check the box in section three of the application.I am applying for a provisional certificate which is available for home care aides whose ability to read, write orspeak English is limited: c Yes c NoSelect if the following applies: c State pay c Self PaySelect if the following applies:c Spouse or Registered Domestic Partner of Military Personnel1. Demographic InformationSocial Security Number (SSN)Birth date (mm/dd/yyyy)(If you do not have a SSN, see instructions)Legal Name:FirstMiddle Male FemaleLastAddressCityStateZip CodeCountyCountryPhone (enter 10 digit #)Cell (enter 10 digit #)Email address for exam notifications (Required)Employer Email (Optional)Personal EmailMailing address if different from above address of record:CityStateZip CodeCountyCountryNote: The mailing and email addresses you provide will be your addresses of record. It is your responsibility tomaintain current contact information on file with the department.Have you ever been known under any other name(s)? Yes NoIf yes, list name(s):Will documents be received in another name? YesIf yes, list name(s):DOH 675-005 September 2020 NoPage 1 of 7

2. Personal Data QuestionsYes No1. Do you have a medical condition which in any way impairs or limits your ability to practice yourprofession with reasonable skill and safety? If yes, please attach explanation. “Medical Condition” includes physiological, mental or psychological conditions ordisorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments,cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes,intellectual disabilities, emotional or mental illness, specific learning disabilities, HIV disease,tuberculosis, drug addiction, and alcoholism.If you answered yes to question 1, explain:1a. How your treatment has reduced or eliminated the limitations caused by your medical condition.1b. How your field of practice, the setting or manner of practice has reduced or eliminated thelimitations caused by your medical condition.Note: If you answered “yes” to question 1, the licensing authority will assess the nature,severity, and the duration of the risks associated with the ongoing medical conditionand the ongoing treatment to determine whether your license should be restricted,conditions imposed, or no license issued.The licensing authority may require you to undergo one or more mental, physical orpsychological examination(s). This would be at your own expense. By submitting thisapplication, you give consent to such an examination(s). You also agree theexamination report(s) may be provided to the licensing authority. You waive all claimsbased on confidentiality or privileged communication. If you do not submit to arequired examination(s) or provide the report(s) to the licensing authority, yourapplication may be denied.2. Do you currently use chemical substance(s) in any way which impair or limit your ability topractice your profession with reasonable skill and safety? If yes, please explain. “Currently” means within the past two years.“Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally.3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism orfrotteurism?. 4. Are you currently engaged in the illegal use of controlled substances?.