​Annual Report of Hearing Testing PM 100 Form

     

Annual Report of Hearing Testing PM 100 Form

  • 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.

 

Please Note

  • 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).  

 

Save and/or Email Your Form

If you plan to save and/or email your form, please follow the instructions below  

  • 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:
    • Typing your districts name onto the form
    • Close the form and save changes
    • Re-open the form to ensure your data and/or changes have been saved
  • Continue to enter your data onto the form. 
  • Close the form and save changes.
  • Open your form to ensure your data has been saved
  • You may email, fax or mail your form to the HCP.  Please refer to the mailing instructions below.  
  • Please only use the PM 100 Form (pdf) that has been provided by the HCP.  

 

Mailing Instructions

  • 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 and/or PM 359 Forms only:  hearingconservationprogram@dhcs.ca.gov
  • Fax:      PM 100 and/or PM 359 Forms only:  (916) 440-5316
  • Mail: All Forms:
    • Hearing Conservation Program
    • Children's Medical Services
    • Department of Health Care Services
    • P.O. Box 997413, MS 8102
    • Sacramento, CA 95899-7413
  • Questions:  Please email your questions to the HCP at:  hearingconservationprogram@dhcs.ca.gov
Last modified date: 10/3/2019 4:27 PM