Daim Ntawv Qhia Txhua Xyoo ntawm Kev Xeem Hnov PM 100 Daim Ntawv
- Annual Report of Hearing Testing PM 100 (pdf). Please submit one form with combined results for each school district .Please note: This form may be emailed, faxed or mailed to the Hearing Conservation Program (HCP). Please follow the instructions listed below.
- Note: Please download the form prior to filling out. If filled out online, the “Tab” navigation / selection may be out of order.
Thov nco ntsoov
- All school districts are required to submit a PM 100, Annual Report of Hearing Testing Form regardless whether a waiver for the 10th and/or 11th grade was requested.
- PM 100 Forms are due by June 30th of each year.
- Please include your school CDC Code on the PM 100.
- If you are uncertain as to what your CDS Code Number is, please visit the Department of Education’s California School Directory (Not DHCS).
- Please only use the State of California HCP PM 100 Form (pdf) that has been provided.
- Adobe Acrobat Reader is required to complete the form. The latest version of Acrobat Reader is available free for downloading at Adobe’s Website (Not DHCS).
Txuag thiab/lossis Email koj daim ntawv
Yog tias koj npaj yuav txuag thiab / lossis email koj daim ntawv, thov ua raws li cov lus qhia hauv qab no
- Adobe Acrobat is required to save HCP PDF forms. If you do not have Adobe Acrobat Reader, the latest version of Acrobat Reader is available free for downloading at Adobe’s Website (Not DHCS).
- Save the PM 100 Form (pdf) to your computer.
- Test the form to ensure your data is being saved to the PM 100 you have saved to your computer by:
- Sau koj lub npe hauv cheeb tsam rau hauv daim ntawv
- Kaw daim ntawv thiab txuag cov kev hloov pauv
- Re-open the form to ensure your data and/or changes have been saved
- Continue to enter your data onto the form.
- Kaw daim ntawv thiab txuag cov kev hloov pauv.
- Open your form to ensure your data has been saved
- Koj tuaj yeem xa email, fax lossis xa koj daim foos mus rau HCP. Thov xa mus rau cov lus qhia hauv qab no.
- Please only use the PM 100 Form (pdf) that has been provided by the HCP.
Cov lus qhia xa ntawv
- Please note: Only the PM 100 and/or PM 359 Forms may be emailed, faxed or mailed. All other forms require an original signature and/or contain confidential information and must be mailed to the HCP at the address listed below.
- Email: PM 100 thiab/lossis PM 359 Cov Ntawv nkaus xwb: hearingconservationprogram@dhcs.ca.gov
- Fax: PM 100 and/or PM 359 Forms only: (916) 440-5316
- Xa ntawv: Txhua Daim Ntawv:
- Qhov Kev Pabcuam Tiv Thaiv Hnov
- Children’s Medical Services
- Department of Health Care Services
- PO Box 997413, MS 8102
- Sacramento, CA 95899-7413
- Cov Lus Nug: Thov xa koj cov lus nug rau HCP ntawm: hearingconservationprogram@dhcs.ca.gov