Form PM359 "Hearing Screening Request Waiver" - California

What Is Form PM359?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2016;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PM359 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form PM359 "Hearing Screening Request Waiver" - California

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State of California
Department of Health Care Services
Health and Human Services Agency
Systems of Care
HEARING SCREENING REQUEST WAIVER
School Year
CDS code number
School district
Address (number and street)
City
ZIP code
Name
Title
Date
Signature
Office Telephone Number
Email Address
A school district may request a waiver of the hearing screening test for tenth and/or eleventh grade
pupils once each school year. This request is for waiver of hearing screening for tenth and/or eleventh
grade pupils.
The California Code of Regulations, Title 17, Section 2951, requires an alternative testing plan that will
ensure that each pupil at risk of hearing loss will receive testing services. Pupils at risk of hearing loss
are:
those exposed to loud noises, including loud music;
pupils that have been referred for testing by a parent or teacher;
pupils for whom there was a previously documented problem;
pupils who have not had a hearing test for three years; and
any pupil who has enrolled for the first time in the district.
We will follow the alternative hearing testing plan as describedabove.
Please submit this form prior to implementing the current year hearing testing program. An
approved waiver ofhearing screening does not exempt a school district from reporting
requirements contained in Section 2951(e).
Submit this request
by one of the following:
California Department of Health Care
DO NOT WRITE IN THIS SPACE
Services
Systems of Care Division
Hearing Conservation
Approved
Not approved
Program
MS 8103
P.O. Box 997413
Reviewed by
Date
Sacramento, CA 95899­
7413
Attention: Health Program Specialist
Fax: (916) 327-1106
Email: HearingConservationProgram@dhcs.ca.gov
PM 359 Rev. (10/16)
State of California
Department of Health Care Services
Health and Human Services Agency
Systems of Care
HEARING SCREENING REQUEST WAIVER
School Year
CDS code number
School district
Address (number and street)
City
ZIP code
Name
Title
Date
Signature
Office Telephone Number
Email Address
A school district may request a waiver of the hearing screening test for tenth and/or eleventh grade
pupils once each school year. This request is for waiver of hearing screening for tenth and/or eleventh
grade pupils.
The California Code of Regulations, Title 17, Section 2951, requires an alternative testing plan that will
ensure that each pupil at risk of hearing loss will receive testing services. Pupils at risk of hearing loss
are:
those exposed to loud noises, including loud music;
pupils that have been referred for testing by a parent or teacher;
pupils for whom there was a previously documented problem;
pupils who have not had a hearing test for three years; and
any pupil who has enrolled for the first time in the district.
We will follow the alternative hearing testing plan as describedabove.
Please submit this form prior to implementing the current year hearing testing program. An
approved waiver ofhearing screening does not exempt a school district from reporting
requirements contained in Section 2951(e).
Submit this request
by one of the following:
California Department of Health Care
DO NOT WRITE IN THIS SPACE
Services
Systems of Care Division
Hearing Conservation
Approved
Not approved
Program
MS 8103
P.O. Box 997413
Reviewed by
Date
Sacramento, CA 95899­
7413
Attention: Health Program Specialist
Fax: (916) 327-1106
Email: HearingConservationProgram@dhcs.ca.gov
PM 359 Rev. (10/16)