Individual hearing outcome report form

What it contains

Blank form to complete information.

• This form should be completed by a WorkSafe contracted hearing service provider in consultation with the injured worker.
• The ratings on the form should represent the individual worker's self-reported judgements.
• The completed form must be sent to the WorkSafe Agent or self-insurer within three to six months following a hearing device fitting.
• 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.