California Form Pm 101 PDF Details

Navigating the process of registration as a school audiometrist in California involves understanding and completing the PM 101 form, a document integral to the profession within the state's education system. This form, issued by the Department of Health Care Services Children’s Medical Services Branch, is a gateway for professionals aiming to work as school audiometrists, ensuring that applicants meet the necessary educational and training prerequisites. It meticulously requires information on personal details, educational background including the highest degree attained, and specifically, courses in audiology and audiometry that have been completed. Additionally, it asks for the applicant's current status or employment, which must align with the state's regulations pertaining to health and educational services. For those employed in positions such as school nurses or within health departments, or for students pursuing relevant fields, this form acts as a formal acknowledgment of their qualifications and aspirations. Importantly, the application includes a section for the Department's use only, emphasizing a bureaucratic review process. Furthermore, instructions on the reverse detail the submission procedures, including necessary documentation like transcripts and a nominal registration fee, providing a clear pathway for applicants to follow. This form mirrors California's commitment to maintaining high standards in health services provided in schools, ensuring that children receive care from qualified professionals.

QuestionAnswer
Form NameCalifornia Form Pm 101
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesAUDIOLOGY, CaliforniaHealth, credential, AUDIOMETRY

Form Preview Example

State of California—Health and Human Services Agency

Department of Health Care Services

 

Children’s Medical Services Branch

 

 

 

DO NOT WRITE IN THIS SPACE

 

 

 

 

 

 

 

APPLICATION FOR REGISTRATION

Certificate number

Date granted

 

 

 

 

 

AS SCHOOL AUDIOMETRIST

 

 

 

Reviewed by

 

 

 

 

 

 

 

 

ｕ Accepted

 

 

 

 

ｕ Not accepted

 

PLEASE PRINT OR TYPE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last name

 

First name

 

 

Initial

Birth date

 

 

 

 

 

 

 

Mailing address

 

City

 

State

ZIP code

Daytime phone

 

 

 

 

 

 

 

EDUCATIONAL BACKGROUND

Name of College or University

Major

Highest

Degree

Year

Conferred

APPROVED COURSES COMPLETED IN AUDIOLOGY AND AUDIOMETRY

College or University

Course

Number

Course Title(s)

Number

of Units

Date

Completed

CURRENT STATUS OR EMPLOYMENT

CHECK:

ｕI am employed as a school nurse by _________________________________ district ______________________________ county.

ｕI am employed by the ________________________________________________________________________ health department.

ｕ I have a California credential in

ｕ speech and hearing

ｕ education of hard of hearing

ｕ education of the deaf

ｕI am a student in (area of) ___________________________________________________________________________________.

ｕOther (specify) ____________________________________________________________________________________________

FOR DEPARTMENT USE ONLY

Acknowledged

APPLICANT’S SIGNATURE

X

Date

(INSTRUCTIONS ON BACK)

PM 101 (09/07)

Page 1 of 2

INSTRUCTIONS

Personnel employed to conduct hearing tests in the schools of California, e.g., SCHOOL AUDIOMETRISTS, as defined in Section 44879 of the Education Code, or qualified SUPERVISORS OF HEALTH, pursuant to Sections 49420 and 49452 of the Education Code, shall be REGISTERED AS SCHOOL AUDIOMETRISTS. Training requirements are prescribed by Section 2950, California Code of Regulations.

Applicants for REGISTRATION AS SCHOOL AUDIOMETRISTS shall submit the following:

ｏCompleted Application, PM 101

ｏTranscript of Record (or official grade cards) verifying satisfactory completion of required training in audiology and audiometry

ｏA registration fee of $10

MAIL THIS APPLICATION WITH OFFICIAL TRANSCRIPT OF RECORD (or grade cards) and $10 REGISTRATION FEE (payable to the California State Department of Health Care Services) to:

California Department of Health Care Services

Accounting Section, Cashiers

MS 1101

P.O. Box 997413

Sacramento, CA 95899-7413

Direct any questions to the Hearing Conservation Specialist at (916) 323-8087.

PM 101 (09/07)

Page 2 of 2

How to Edit California Form Pm 101 Online for Free

Any time you intend to fill out AUDIOMETRISTS, there's no need to download and install any sort of applications - simply try our online tool. Our team is devoted to giving you the perfect experience with our editor by regularly introducing new features and enhancements. Our tool is now a lot more helpful as the result of the latest updates! Currently, editing PDF forms is easier and faster than before. Getting underway is easy! All you have to do is stick to the next simple steps down below:

Step 1: First, access the tool by clicking the "Get Form Button" at the top of this page.

Step 2: With our state-of-the-art PDF tool, it's possible to do more than just complete forms. Express yourself and make your docs seem great with customized textual content added in, or adjust the file's original input to excellence - all comes along with an ability to incorporate any type of pictures and sign the file off.

This PDF doc will require specific details; to guarantee correctness, be sure to adhere to the next guidelines:

1. It's important to fill out the AUDIOMETRISTS properly, thus be mindful while working with the parts that contain these particular blanks:

look up school audiometrist certificate conclusion process detailed (portion 1)

2. Soon after finishing the previous step, go to the subsequent stage and fill in the essential particulars in all these fields - CHECK, ｕ I am employed as a school nurse, ｕ I am employed by the health, ｕ I have a California credential in, ｕ speech and hearing, ｕ education of hard of hearing, ｕ education of the deaf, ｕ I am a student in area of , ｕ Other specify , FOR DEPARTMENT USE ONLY, Acknowledged, APPLICANTS SIGNATURE, Date, INSTRUCTIONS ON BACK, and PM .

The best ways to complete look up school audiometrist certificate part 2

You can easily make errors when filling out your FOR DEPARTMENT USE ONLY, and so be sure you go through it again before you decide to submit it.

Step 3: Always make sure that the details are right and then simply click "Done" to progress further. Download the AUDIOMETRISTS once you sign up for a 7-day free trial. Immediately access the document inside your personal account, with any modifications and adjustments conveniently synced! FormsPal offers secure form tools with no personal data record-keeping or any sort of sharing. Rest assured that your details are in good hands here!

California Form Pm 101 isn’t the one you’re looking for?

Related Documents