Hearing Assessment And Device Exception Request Form


  • Hearing Assessment and Device Exception Request Form (PDF 178kb)
    Document Type: Form
    Keycode: FOR823/01/12.11
    Date First Published: 07 December 2011
    Summary: The Hearing Assessment and Device Request Form outlines the information required by a WorkSafe 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 Worksafe Approved Hearing Device List.

About this form


The Hearing Assessment and Device Request Form outlines the information required by a WorkSafe 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 Worksafe Approved Hearing Device List. This form should be completed by audiologists/audiometrists approved by WorkSafe to provide hearing services to injured workers and submitted to the WorkSafe 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.