Child Health and Disability Prevention Program Forms

The following are forms for the Child Health and Disability Prevention Program.

If you do not see the form you need, please check if it can be ordered through the Children's Medical Services (CMS) Catalog or contact us and we will try to accommodate your request.

• Application for Registration as a School Audiometrist - PM 101
• Annual Report of Hearing Testing - PM 100

• CHDP Referral - PM 357
• Confidential Referral/Follow-Up Report - PM 161
• Confidential Screening/Billing Report - PM 160 (Refer to EDS Print and Distribution Section, Page 10 of the CMS Catalog) 
• Consent Form - PM 211 (Bilingual) 
• Facility Review Scoring Summary Sheet - DHCS 4494
• Facility Review Tool and Scoring Instructions - DHCS 4493 and Guidelines
• Facility Review Tool and Scoring Instructions - DHCS 4492 (Sample Fill-In Form 2 (Courtesy of Nathalie C.), Sample Fill-In Form 3 (Courtesy of Lee F.) (Updated 2/14/14)
• Health Assessment Provider Agreement - DHCS 4491
• Health Assessment Provider Application - DHCS 4490
• Hearing Screening Request Waiver - PM 359
• Laboratory Provider Program Agreement - DHCS 4503
• Laboratory Provider Application - DHCS 4502
• Medical Record Review Tool - DHCS 4492 and Guidelines
• Pre-Enrollment Application - DHCS 4073
• Pre-Enrollment Application - DHCS 4073 (Arabic)
• Pre-Enrollment Application - DHCS 4073 (Armenian)
• Pre-Enrollment Application - DHCS 4073 (Cambodian)
• Pre-Enrollment Application - DHCS 4073 (Chinese)
• Pre-Enrollment Application - DHCS 4073 (Farsi)​​
  
• Pre-Enrollment Application - DHCS 4073 (Hmong)
• Pre-Enrollment Application - DHCS 4073 (Korean)
• Pre-Enrollment Application - DHCS 4073 (Russian)
• Pre-Enrollment Application - DHCS 4073(Spanish)
• Pre-Enrollment Application - DHCS 4073(Tagalog)
• Pre-Enrollment Application - DHCS 4073(Vietnamese)
• Provider Data Sheet - PM 177
• Registration of Agency Intending to Provide Hearing Testing Services Per Section 49452, California Education Code - PM 210
• Report of Distribution - DHCS 4504
• Report of Health Examination for School Entry - PM 171 A (Bilingual)
• Telecommunications Provider and Biller Application/Agreement - DHCS 4431
• Waiver of Health Examination for School Entry - PM 171 B (Bilingual)
• Nutrition Screening Form (Ages Birth to Eight) - What Does Your Child Eat? - DHCS 4035 A - What Does Your Child Eat? SPANISH
• Nutrition Screening Form (Ages 8 to 19) - What Do You Eat? food Frequency Questionnaire and Youth Nutr​ition and Activity Assessment - DHCS 4466 - What Do You Eat? SPANISH
• Youth Nutrition and  Activity Assessment - DHCS 4035 B ​