California Hearing Conservation Program Forms - DHCS: Fill out & sign online

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Click ‘Get Form’ to open the California Hearing Conservation Program Forms - DHCS in the editor.
Begin by filling out the identifying information, including the reporting school year, CDS Code Number, and district details such as name, email address, and address.
In Column (1), list all grades within your district that require screening. Remember that grades marked with an asterisk must have all students screened.
For Column (2), enter the total number of students enrolled in each grade as of October's CALPADS report.
Proceed to Column (3) and input the number of students screened according to Section 2951(c), CCR, Title 17.
In Column (4), record how many students failed both threshold tests as per Section 2951(d).
Complete Columns (5) and (6) by detailing the number of students referred for medical evaluation and those examined or under treatment.
Once completed, utilize our platform’s ‘E-mail’ button to send your form directly or select ‘Print’ to mail or fax it.

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