Get Look Up School Audiometrist Certificate

Department of Health Care Services Children s Medical Services Branch State of California Health and Human Services Agency DO NOT WRITE IN THIS SPACE APPLICATION FOR REGISTRATION AS SCHOOL AUDIOMETRIST Certificate number Date granted Reviewed by Accepted Not accepted PLEASE PRINT OR TYPE. Last name First name Mailing address Initial City State Birth date 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 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 I am a student in area of. Other specify FOR DEPARTMENT USE ONLY Acknowledged APPLICANT S SIGNATURE X INSTRUCTIONS ON BACK PM 101 09/07 Page 1 of 2 Personnel employed to conduct hearing tests in the schools of California e*g* 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. I am employed by the health department. I have a California credential in speech and hearing education of hard of hearing I am a student in area of. Other specify FOR DEPARTMENT USE ONLY Acknowledged APPLICANT S SIGNATURE X INSTRUCTIONS ON BACK PM 101 09/07 Page 1 of 2 Personnel employed to conduct hearing tests in the schools of California e*g* 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. Other specify FOR DEPARTMENT USE ONLY Acknowledged APPLICANT S SIGNATURE X INSTRUCTIONS ON BACK PM 101 09/07 Page 1 of 2 Personnel employed to conduct hearing tests in the schools of California e*g* 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.