Audiometric Report

Saint John Office

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WorkSafeNB claim number Medicare number

Worker information
Worker’s last name First name Initial

Date of birth

Health care provider information

Provider name Provider number

Completed by Date reported Phone number

Speech audiometry Middle ear function

Right Left Acoustic reflexes
Otoscopy
HTL Earphones

SRT dB SN L dB dB SN R dB Contra .5K 1K 2K 4K Supra-aural

reflex Insert
WRS
RE
with % SN L dB % SN R dB threshold
recorded at dB at dB
Stimulus ear

Reliability
LE
voice
Ipsi Good
MCL
reflex RE Fair
UCL
threshold Poor
LE

Tympanogram

MEP daPa ECV ml SC ml

RE

LE
 Audiometric Report

Audiogram
RIGHT EAR PURETONE AUDIOGRAM Frequency in hertz LEFT EAR PURETONE AUDIOGRAM Frequency in hertz

250 500 1000 2000 3000 4000 6000 8000 250 500 1000 2000 3000 4000 6000 8000
-10 -10 -10 -10

0 0 0 0

10 10 10 10
Threshold in Decibels (dBHL)

Threshold in Decibels (dBHL)

20 20 20 20

30 30 30 30

40 40 40 40

50 50 50 50

60 60 60 60

70 70 70 70

80 80 80 80

90 90 90 90

100 100 100 100

110 110 110 110

Please insert air conduction thresholds if the loss is sensorineural, and insert bone conduction thresholds, in addition, only if the loss is
conductive or mixed

Key to audiometric symbols

0 = right unmasked air > = left unmasked bone
X = left unmasked air [ = right masked bone
∆ = right masked air ] = left masked bone
= left masked air C = contralateral reflex
< = right unmasked bone I = ipsilateral reflex

Audiologic assessment
Audiometry Test behaviours
Yes    No SRT vs. PTA (.5k, 1k, 2k, OR .5k, 1k AVG.) ± Yes    No Atypical response patterns
7-10 dB
Yes    No Test inconsistency
Yes    No Tympanometry agrees with nature of hearing
Yes    No Unusual speech audiometric patterns or
loss
responses
Yes    No Acoustic reflexes as anticipated for nature and
Yes    No Discrepancy between history, thresholds and/
degree of hearing loss
or behaviours outside test booth
If NO to any of the above, provide details: If YES to any of the above, provide details:

Confirm the worker was reportedly free of hazardous noise exposure for 16 hours immediately prior to assessment    Yes    No

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 Audiometric Report

Results
Degree of Hearing Loss Type of Hearing Loss Middle Ear Function
   R    L Normal (0-15 dBHL)    R    L High Frequency    R    L Normal Tympanogram
   R    L Minimal (16-25 dBHL)    R    L Low Frequency    R    L Negative Middle Ear Pressure
   R    L Mild (26-40 dBHL)    R    L Conductive    R    L Flat/Round Tympanogram
   R    L Moderate (41-55 dBHL)    R    L Sensorineural    R    L High Compliance
   R    L Moderate-Severe (56-70 dBHL)    R    L Mixed    R    L Low Compliance
   R    L Severe (71-90 dBHL)    R    L Absent/Elevated Acoustic Reflexes
   R    L Profound (91+ dBHL)    R    L Large Physical Volume

Medical information
Other relevant history reported Yes No Right Left Details
(if yes provide details)

Tinnitus

Dizziness/imbalance

Facial numbness

Head injury

Familial hearing loss

Chronic disease (diabetes, etc.)

Medications

Meniere’s

Ear disease and/or ear or cranial

surgery (otalgia, otorrhea, etc)

Noise exposure, onset and progression

Yes No Don’t know

Are early audiograms or ENT consults available for review? If yes, please submit.

Did the onset and progression of the hearing loss develop in the first 10-15 years of noise exposure?

Did the hearing loss initially develop as a “notch” in the 3000-6000 Hz region with a better threshold
at the next higher frequency, of at least 15dB?

Did the hearing loss develop symmetrically (< 15dB difference)?

If NO to any of the above, please explain:

Has there been any non-occupational noise exposure? If yes, please provide details:

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