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California Hearing Conservation Program Forms

Due to the high volume of reports received, you will not receive confirmation of a report received. Please use Hearing Conservation Program(HCP) Forms only.  For email, fax or mailing instructions, please refer to the ​mailing instructions listed below.  

To view or save forms to your computer, you must have Adobe Acrobat.  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).  

HCP FORMS — Please use only the State HCP forms provided below

• Annual Report of Hearing Testing  PM 100 (pdf)  
  This form may be emailed, faxed or mailed to the HCP.  Please refer to the instructions below. 
• Hearing Screening Request Waiver  PM 359 (pdf)
  Please Note:  This form may be emailed, faxed or mailed to the HCP.  Please refer to the instructions below. 
• Application For Registration As School Audiometrist DHCS 101 (pdf)
  ** Please Note:  This form contains confidential information and/or requires an original signature. 
                          This form will need to be mailed to the HCP address listed below.
• Registration Of Agency Intending To Provider Hearing Testing Services  PM 210 (pdf)
  ** Please Note:  This form contains confidential information and/or requires an original signature. 
                          This form will need to be mailed to the HCP address listed below.

If Saving or Emailing your Form

1. The forms are PDF Forms and you must have Adobe Acrobat Reader.  If you not have Adobe Acrobat Reader, the latest version is available free for downloading at Adobe's Website (Not DHCS). 
2. Enter the School District name to the form, save and close the form
3. Re-open the form to ensure your data and/or changes have been saved
4. Enter your data onto the form 
5. Save and close the form
6. Before emailing the form, check the form to ensure all of your data has been saved
7. Email the form to the HCP email address listed below
8. Please only use HCP forms provided on this website
9. Please note:  Only PM 100 and PM 359 Forms can be emailed or faxed.  All other forms requiring original signature and/or contain confidential information must be mailed to the address listed below. 

Mailing Instructions​

• Email: hearingconservationprogram@dhcs.ca.gov   Please Note: Only the PM 100 and/or PM 359 Forms may be emailed, faxed or mailed.  All other forms require original signature and/or contain confidential information and must be mailed to the HCP address listed below.
• Fax:    (916) 323-5316  -  Please Note: Only the PM 100 and/or PM 359 Forms may be emailed, faxed or mailed.  All other forms require original signature and/or contain confidential information and must be mailed to the HCP address listed below.
• Mail:   ** All forms may be mailed to the HCP address listed below. 

Hearing Conservation Program
Children's Medical Services
Department of Health Care
P.O. Box 997413, MS 8102
Sacramento, CA  95899-7413​