Hearing Assessment And Device Exception Request Form

  • Hearing Assessment and Device Exception Request Form (PDF 108kb)
    Document Type: Form
    Keycode: FOR823/02/05.14
    Version: 2.0
    Publication Date: 30 June 2014
    Date First Published: 07 December 2011
    Summary: The Hearing Assessment and Device Request Form outlines the information required by a VWA Agent to consider a request for an unlisted hearing device in exceptional circumstances where an individual worker's functional communication requirements cannot be met by any device on the VWA Approved Hearing Device List.

About this form

The Hearing Assessment and Device Request Form outlines the information required by a VWA Agent to consider a request for an unlisted hearing device in exceptional circumstances where an individual worker's functional communication requirements cannot be met by any device on the VWA Approved Hearing Device List. This form should be completed by audiologists/audiometrists approved by VWA to provide hearing services to injured workers and submitted to the VWA Agent prior to the provision and fitting of a hearing device or assistive listening device. It is recommended that hearing service providers do not fit the requested hearing devices until they have been advised in writing that the request has been approved.