Get California Pm 101 Form

Get California Pm 101 Form

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.

Structure

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.

California Pm 101 Preview

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

 

 

 

 

 

 

 

 

Accepted

 

 

 

 

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:

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

I am employed by the ________________________________________________________________________ health department.

I have a California credential in

speech and hearing

education of hard of hearing

education of the deaf

I am a student in (area of) ___________________________________________________________________________________.

Other (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:

Completed Application, PM 101

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

A 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

Document Data

Fact Name Description
Governing Law The PM 101 form is governed by Section 44879 and Sections 49420 and 49452 of the California Education Code.
Purpose This form serves as an application for registration as a School Audiometrist in California.
Required Documentation Applicants must submit a completed PM 101 form, a transcript verifying training in audiology and audiometry, and a $10 registration fee.
Application Review The application is reviewed by the California Department of Health Care Services, which will accept or not accept the application.
Contact Information For inquiries, applicants can contact the Hearing Conservation Specialist at (916) 323-8087.

How to Use California Pm 101

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.

  1. Personal Information: Begin by entering your last name, first name, and middle initial in the designated fields.
  2. Birth Date: Fill in your birth date in the specified format.
  3. Mailing Address: Provide your complete mailing address, including city, state, and ZIP code.
  4. Daytime Phone: Enter your daytime phone number where you can be reached.
  5. Educational Background: List the name of the college or university you attended, your major, the highest degree you obtained, and the year it was conferred.
  6. Approved Courses: Document the college or university where you completed your audiology and audiometry courses. Include the course number, title(s), number of units, and date completed.
  7. Current Status or Employment: Check the appropriate box that describes your current employment status or educational pursuit. Provide any necessary details in the space provided.
  8. Signature: Sign and date the application to certify the information is accurate.

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.

Key Facts about California Pm 101

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.

Common mistakes

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.

Documents used along the form

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.

  • Transcript of Records: This document provides official proof of the applicant's educational background. It verifies the completion of required courses in audiology and audiometry, ensuring that the individual has met the educational standards set by the state.
  • Official Grade Cards: Similar to transcripts, grade cards serve as an alternative form of verification for coursework completed. They detail the applicant's performance in relevant subjects, further supporting their qualifications for registration.
  • Registration Fee Payment: A fee of $10 must accompany the PM 101 form. This payment is necessary for processing the registration application. It is typically submitted via check or money order made out to the California State Department of Health Care Services.
  • Application for Employment: If applicable, this document outlines the applicant's current employment status. It details their position and the organization they work for, which may be relevant in assessing their experience in the field.
  • California Credential Documentation: Applicants who hold a California credential in related fields, such as speech and hearing or education of the deaf, should provide documentation of these credentials. This information may enhance their application by demonstrating additional qualifications.
  • Supplemental Information Form: This optional form allows applicants to provide additional context about their professional experience or training. It can be beneficial for those who wish to highlight specific skills or experiences that may not be fully captured in the PM 101 form.

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.

Similar forms

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:

  • California PM 100 Form: This form is used for the registration of school nurses. Like the PM 101, it requires educational background and proof of qualifications.
  • California Speech-Language Pathology License Application: This application is for individuals seeking licensure as speech-language pathologists. Both documents require verification of educational credentials and relevant coursework.
  • California Occupational Therapy License Application: Similar to the PM 101, this application necessitates proof of educational qualifications and completion of required clinical experience.
  • California Registered Nurse License Application: This document is essential for obtaining a nursing license in California. Both forms require proof of education and training in the respective fields.
  • California Physician Assistant License Application: This application is for those seeking to become licensed physician assistants. It shares the need for educational verification and completion of specific training programs.
  • California Medical Board Application: This application is for physicians seeking licensure. Similar to the PM 101, it requires detailed educational history and proof of medical training.
  • California Physical Therapy License Application: This document is for physical therapists. Like the PM 101, it mandates proof of educational credentials and clinical experience.
  • California Marriage and Family Therapist Registration Application: This application is for individuals seeking to become registered marriage and family therapists. Both documents require educational background and completion of specific coursework.

Dos and Don'ts

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.

  • Do print or type your information clearly. Legibility is crucial for processing.
  • Do include all required documents, such as your official transcript and registration fee.
  • Do double-check your application for accuracy before submission.
  • Do provide a valid daytime phone number for any follow-up questions.
  • Don't leave any sections blank. Fill out all required fields to avoid delays.
  • Don't forget to sign and date the application. An unsigned application will be rejected.
  • Don't submit the application without the registration fee. It must accompany your form.
  • Don't write in the space marked "DO NOT WRITE IN THIS SPACE." This area is reserved for official use only.

Misconceptions

Misconceptions about the California PM 101 form can lead to confusion for applicants. Here are ten common misunderstandings, clarified for your benefit:

  1. Only teachers can apply for the PM 101 form. This is not true. While teachers may use the form, it is designed for various professionals, including school nurses and health department employees.
  2. The PM 101 form is only for new applicants. In reality, this form can also be used for renewals and updates to existing registrations.
  3. Submitting the PM 101 form guarantees approval. Approval is not guaranteed. The application must meet all requirements, and the decision rests with the reviewing authority.
  4. There is no fee associated with the PM 101 form. This is incorrect. A registration fee of $10 is required when submitting the application.
  5. Only specific colleges are recognized for audiology training. Any accredited institution that offers approved courses in audiology and audiometry is acceptable.
  6. Applicants must have a teaching credential to apply. This is a misconception. While a credential may be beneficial, it is not a prerequisite for applying.
  7. The PM 101 form is only relevant for public schools. This form applies to both public and private educational institutions in California.
  8. All courses taken in audiology count towards the application. Only approved courses specified in the application will be considered valid.
  9. Once submitted, the application cannot be changed. Applicants can update their information before the application is processed, but changes may not be allowed afterward.
  10. The PM 101 form is a lengthy process that takes months. While processing times can vary, many applications are reviewed relatively quickly, depending on the completeness of the submission.

Understanding these misconceptions can help streamline the application process and ensure that applicants are adequately prepared when submitting the PM 101 form.

Key takeaways

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:

  • Complete All Sections: Ensure every section of the form is filled out accurately, including personal information and educational background.
  • Provide Official Documentation: Attach a transcript or official grade cards that verify your training in audiology and audiometry.
  • Registration Fee: Include a $10 registration fee, made payable to the California State Department of Health Care Services.
  • Employment Status: Clearly indicate your current employment status or educational status in the designated section.
  • Mailing Instructions: Send the completed form, transcripts, and fee to the specified address to avoid processing delays.
  • Contact Information: If you have questions, reach out to the Hearing Conservation Specialist at the provided phone number for assistance.
  • Signature Required: Don’t forget to sign and date the application before submission to validate your request.

By following these steps, you can ensure that your application is complete and meets all requirements for registration as a school audiometrist in California.