Individual hearing outcome report form

Use this form to record an individual hearing outcome report about workers and their hearing devices.


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.