1-833-4CA4ALL Name and Title of Authorized Official (please print or type) Name of Agency Receiving/Requesting Funding. 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. Please refer to CDPH website. HS 200 Author: CDPH Keywords: HS 200,Licensure & Certification Application,CDPH,Licensing and Certification,internet form Last modified by: Tammy Schmitt Created Date: 3/13/2019 8:17:00 PM Company: State Of Wyoming Other titles: Licensure & Certification Application Last updated: 1/4/2021 A.8.a. By Program Street Address City, State, Zip Code. 1. Reset Fill out, securely sign, print or email your hs200 form instantly with SignNow. 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 If information on the officers or board members is incorrect because the information has changed, resubmit the Administrative Organization form (HS 309). Please turn on JavaScript and try again. For existing facilities, complete both columns.  If the licensee, facility, or property information is incorrect because the information has changed, resubmit the L&C Application form (HS 200). If you are evacuated due to wildfires, bring a face covering and hand sanitizer and continue to practice physical distancing when possible to protect against COVID-19. Proposed facility bed capacity 9. It looks like your browser does not have JavaScript enabled. CDPH Releases Reports on Healthcare-Associated Infections, Influenza Vaccination Rates Among Healthcare Personnel CDPH Warns Consumers Not to Eat … Decrease, Reset MS 0500 Español, - (916) 558-1784, COVID 19 Information Line: U.S. Department of Health & Human Services Office for Civil Rights. 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 The license fee '' HS 200 ( PDF ) - Licensure and 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