Hearing assessment and device exception request form

What it contains

This form should be completed by the audiologist or audiometrist approved by WorkSafe to provide hearing services to injured workers with a work-related hearing loss and who has performed the assessment on the worker. The completed form must be sent to the WorkSafe Agent or self-insurer following assessment. All sections should be completed. Please provide reasons if you are unable to complete a section of the form as incomplete forms may be returned to you for further information.