Hearing assessment and device 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.