Hearing assessment and device exception request form

Audiologists or audiometrists can use this form to request a device for an injured worker that is not on the WorkSafe approved hearing device list.

Published: 01 May 2014
File type: PDF
File size: 107.57 kB
Length: 4 pages
Reading level: Medium

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.