The California PM 101 form is an application for registration as a school audiometrist. This form is essential for individuals who conduct hearing tests in California schools. If you are ready to take the next step, fill out the form by clicking the button below.
The California PM 101 form serves as a crucial application for individuals seeking registration as school audiometrists within the state's educational system. This form is specifically designed for personnel responsible for conducting hearing tests in California schools, ensuring that they meet the necessary qualifications outlined in the Education Code. Applicants must provide personal information, including their name, contact details, and educational background, while also documenting their completed courses in audiology and audiometry. The form requires verification of the highest degree attained and the relevant training completed. Additionally, it prompts applicants to indicate their current employment status, whether they are school nurses, health department employees, or pursuing further education in related fields. A registration fee of $10 is also required, along with official transcripts to confirm the completion of necessary coursework. Clear instructions guide applicants through the submission process, emphasizing the importance of thoroughness in providing accurate information. This structured approach helps ensure that only qualified individuals are registered to perform essential hearing tests, ultimately contributing to the health and well-being of students across California.
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)
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
(INSTRUCTIONS ON BACK)
PM 101 (09/07)
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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.
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Completing the California PM 101 form is a straightforward process. Follow these steps carefully to ensure your application is filled out correctly. Once submitted, your application will be reviewed, and you will receive further instructions based on your application status.
Once you have completed the form, gather your official transcript or grade cards verifying your training in audiology and audiometry, along with a $10 registration fee. Mail these items to the specified address for processing.
What is the California PM 101 form?
The California PM 101 form is an application for registration as a school audiometrist. This form is essential for personnel who conduct hearing tests in California schools. It is a requirement under the Education Code for individuals to be registered as school audiometrists or qualified supervisors of health. The form gathers personal information, educational background, and current employment status, ensuring that applicants meet the necessary qualifications for this role.
Who needs to fill out the PM 101 form?
Individuals who wish to conduct hearing tests in California schools must complete the PM 101 form. This includes school audiometrists and qualified supervisors of health. To be eligible, applicants must have completed specific training in audiology and audiometry. Additionally, those currently employed as school nurses or holding a California credential in related fields may also need to register using this form.
What documents are required to submit with the PM 101 form?
To successfully submit the PM 101 form, applicants must include several documents. These include a completed application form, a transcript of records or official grade cards verifying the completion of required training in audiology and audiometry, and a registration fee of $10. All these materials must be mailed together to the California Department of Health Care Services for processing.
Where do I send the completed PM 101 form?
The completed PM 101 form, along with the required documents and registration fee, should be mailed to the California Department of Health Care Services. The address is: Accounting Section, Cashiers MS 1101, P.O. Box 997413, Sacramento, CA 95899-7413. It is important to ensure that all materials are included in the submission to avoid delays in processing.
How can I get help if I have questions about the PM 101 form?
If you have questions regarding the PM 101 form or the registration process, you can contact the Hearing Conservation Specialist at the California Department of Health Care Services. The phone number for assistance is (916) 323-8087. It is advisable to reach out for clarification to ensure that your application is completed correctly.
When filling out the California PM 101 form, applicants often make several common mistakes that can lead to delays or even rejection of their application. Understanding these pitfalls can significantly improve the chances of a successful submission.
One frequent error is failing to provide complete and accurate personal information. The form requires specific details such as the applicant's last name, first name, initial, birth date, and mailing address. Omitting any of this information can result in an incomplete application. It is crucial to double-check that all fields are filled out correctly and legibly.
Another mistake involves neglecting to include the necessary educational background information. The form asks for details about the college or university attended, the major, the highest degree earned, and the year it was conferred. If this section is left blank or filled out incorrectly, it can raise questions about the applicant's qualifications and hinder the review process.
Applicants often overlook the section that requires documentation of approved courses completed in audiology and audiometry. This includes providing the college or university name, course number, course title, number of units, and date completed. Incomplete or inaccurate course information can lead to confusion regarding the applicant's training and may result in a denial.
Additionally, applicants may fail to select their current status or employment accurately. The form provides several options, including employment as a school nurse or a health department employee, as well as other categories. Not checking the appropriate box or providing additional information can create ambiguity about the applicant's professional background, which is essential for the evaluation of the application.
Lastly, neglecting to sign and date the application is a critical oversight. The applicant's signature confirms that all information provided is true and accurate to the best of their knowledge. Without a signature and date, the application may be deemed invalid, leading to unnecessary delays in the registration process.
The California PM 101 form is a crucial document for individuals seeking registration as school audiometrists. However, several other forms and documents are often required or recommended to accompany this application. These documents help ensure that applicants meet the necessary qualifications and facilitate the registration process. Below is a list of these important forms and documents.
In summary, while the California PM 101 form is essential for registration as a school audiometrist, it is often accompanied by several other documents that collectively support the applicant's qualifications. Ensuring that all necessary forms are completed and submitted can significantly enhance the chances of a successful application.
The California PM 101 form is used for the registration of school audiometrists. Several other documents share similarities with the PM 101 form, primarily in their purpose of certifying qualifications or registering professionals in health-related fields. Here are eight documents that are comparable:
When filling out the California PM 101 form, it is essential to follow specific guidelines to ensure your application is processed smoothly. Below is a list of things you should and shouldn't do.
Misconceptions about the California PM 101 form can lead to confusion for applicants. Here are ten common misunderstandings, clarified for your benefit:
Understanding these misconceptions can help streamline the application process and ensure that applicants are adequately prepared when submitting the PM 101 form.
When filling out the California PM 101 form, it's essential to follow specific guidelines to ensure a smooth application process. Here are seven key takeaways:
By following these steps, you can ensure that your application is complete and meets all requirements for registration as a school audiometrist in California.