Individual hearing outcome report form

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

Published: 01 Dec 2008
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.