Fillable AS SCHOOL AUDIOMETRIST APPLICATION FOR REGISTRATION (Department of Health Care Services)

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AS SCHOOL AUDIOMETRIST APPLICATION FOR REGISTRATION (Department of Health Care Services)

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State of California—Health and Human Services Agency Department of Health CareServices
Integrated Systems of Care Division
APPLICATION FOR REGISTRATION
AS SCHOOL AUDIOMETRIST
PLEASE PRINT OR TYPE
DO NOT WRITE IN THIS SPACE
Certificate number Date granted
Approved
Not Approved
Reviewed by
Last name
First name
Middle Initial
Mailing address
City State ZIP code
Daytime phone
Email address
EDUCATIONAL BACKGROUND
OR
APPROVED COURSES COMPLETED IN AUDIOLOGY AND AUDIOMETRY
Name of College or University
Course
Number
Course Title(s)
Number
of Units
Date
Completed
APPLICANT’S SIGNATURE
DATE
PM 101 (08/18)
Page 1 of 2
click to sign
signature
click to edit
Page 2 of 2
REQUIREMENTS
Audiometrists employed to conduct hearing tests in California schools 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 described in
Section 2950, California Code of Regulations.
Applicants applying for registration as school Audiometrists shall mail the
following:
•
Completed, PM 101 (08/18) Application
•
An official copy of a transcript verifying satisfactory completion of required
training in audiology and audiometry. A certificate of completion verifying
satisfactory training in audiology and audiometry will be accepted in lieu of a
transcript.
•
A $10 registration fee is required at the time of submission in the form of a
cashier’s check, money order or personal check payable to the California
Department of Health Care Services.
Integrated Systems of Care Division
Provider Enrollment Unit
1501 Capitol Ave., MS 4502
P.O. Box 997437
Sacramento, CA 95899-7437
If you have further questions, you may contact us at
providerpaneling@dhcs.ca.gov
or call (916) 552-9105, option 5, and t hen
option 2.
PM 101 (08/18)
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AS SCHOOL AUDIOMETRIST APPLICATION FOR REGISTRATION (Department of Health Care Services)

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Completed 23 November 2020

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