Hearing Assessment and Device Request Form (Word)
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Hearing Assessment and Device Request Form (Word) (DOC 522kb)
Document Type: Form
Keycode: FOR717/05/12.11
Date First Published: 22 December 2011
Summary: The Hearing Assessment and Device Request Form outlines the information required by a WorkSafe Agent to consider a request for a hearing device or assistive listening device. 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.
