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AUDIOMETRY HEALTH SURVEILLANCE FORM

PART 1 – To be completed by the Employee

DOB
Month
Day
Year

Hearing Protection

Do you wear hearing protection at work?
If ‘YES’, what do you wear?
Have you worn hearing protection in previous employment?

Medical History

Do you consider your hearing to be:
Do you have difficulty hearing when there is a lot of background noise? e.g. TV/Music/Groups of people talking
Is there a family history of deafness?

Do you have a history of:

being knocked unconscious?
dizziness or vertigo
hearing loss due to an illness or injury?
surgery to ears?
ear syringing due to ear wax?
treatment for TB or malaria?
noise in ears?
exposure to gunfire/explosions?
exposure to noise in a previous occupation?
exposure to noise in your leisure activities? e.g. music concerts, motorcycles, shooting, DIY

PART 2 – to be completed by Occupational Health Nurse

If offsite, please note the audiometers:

Otoscopic Examination

Left Ear Is there wax in the internal meatus?
Right Ear Is there wax in the internal meatus?
Left Ear Tympanic Membrane
Right EarTympanic Membrane

Audiometry

Sum of hearing and HSE Category:

Left Ear

0.5 1 2 3 4 6 8

Right Ear

0.5 1 2 3 4 6 8

Left KHz
Right KHz
Left Db
Right Db
Left 1,2,3,4 & 6 KHz
Right 1,2,3,4 & 6 KHz
Left 1,2,3 & 4 KHz
Right 1,2,3 & 4 KHz
Left 3,4 & 6 KHz
Right 3,4 & 6 KHz
Left HSE Category
Right HSE Category
Left Overall HSE Category
Right Overall HSE Category
Change since previous test
Recommendations
Date of next audiogram:
Month
Day
Year
Certificate to company:

Assessor

Date
Month
Day
Year
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