Published: 01 Dec 2008
Individual hearing outcome report form
Use this form to record an individual hearing outcome report about workers and their hearing devices.
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Download the PDF before filling it in
Important: Please download this PDF to your computer. You can fill it in using Adobe Reader as it may not save if you attempt to fill it in using your web browser.
File type: PDF
File size: 88.63 kB
Length: 2 pages
Reading level: Medium
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.