Mail completed forms to: Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 Name 1. When did you first notice your hearing loss? 3. What kind(s) of hearing problems are you having? (Circle letter of all applicable items.) Claim Number Occupational Hearing Loss Questionnaire Injury Date 2. Was the onset of the hearing loss: 4. While employed, did your hearing loss interfere with your work? Sudden No Gradual A. Ringing in ears. B. Difficulty hearing on the phone. C. Difficulty hearing spoken communication in one-onone conversation. D. Difficulty understanding spoken communication in the presence of surrounding noise. E. Other ­ explain: 5. Name and address of doctor who told you your hearing loss was occupational? Name Address City State Zip Code Yes ­ explain below: 6. How were you notified? Written (please attach a copy) Oral Other ­ explain below: 7. Have you been examined by any other doctor in the past for hearing loss: No Yes ­ please provide: Doctor's Name Address City Exam Date Doctor's Name Address City Exam Date State Audiogram Done? Zip Code State Audiogram Done? Zip Code 8. When you were first told by a doctor that your hearing loss was caused by work noise, did he/she also tell you that you should have: A. Medical Treatment ­ No Yes ­ explain below: B. A hearing aid ­ No Yes C. Did you have an audiogram? No Yes 9. Have you ever had hearing aids in the past? No Yes No Yes ­ please provide: Doctor's Name/Clinic Name Address City State Zip Code No Yes 10. Do you have a health problem for which you must take medication on a regular basis? No Yes ­ explain the health problem and what kind of medication you are taking below: 12. Have you had any injury to your ear(s)? 11. Name and address of doctor prescribing your medications: Doctor's Name Address City State Zip Code No Yes ­ explain below: F262-016-000 Occupational Hearing Loss Questionnaire 06-2015 American LegalNet, Inc. www.FormsWorkFlow.com 13. Have you had any illness that affected your ears or hearing? 14 Have you ever had a head injury? No No Yes ­ indicate when and name of illness: 15. Have you had any illness involving high fever? Yes ­ describe the injury below: No Yes ­ indicate when and name of illness: 16. Have any members of your family suffered hearing loss? No Yes ­ specify relationship (mother, father, uncle, etc): 17. Were you a member of a union or trade when exposed to the noise that you think contributed to your hearing loss? No Yes ­ which union? 18. Do you have any hobbies of non-work activities which involved loud noise such as: (check all that apply) Loud Music Auto Repair Woodworking Metal Working Wood Cutting Snowmobiling Motorbiking Boating Hunting/Target Practicing Auto Racing Flying Aircraft Operating Noisy Equipment such as: Tractors Farm Equipment Lawn Mowers Other ­ please specify: How Long (time/duration)? 19. Type of equipment or tools used for hobbies: How Often? Please list any hobbies or activities you participate in that involve noise? 20. Current or last rate of pay: Amount: $ Rate of pay: 21. Are you retired? Hour Day Week Month No 21A. If you're retired, why did you retire? 21B. If you're retired, what is the last date you worked when you were exposed to noise that you think contributed to your hearing loss? (Give the month and year.) 21C. Did you have a hearing test as any part of a physical exam when you retired? Yes No 22. Was your employer contributing to your and/or your family's medical dental, and/or vision insurance on the last day you worked when exposed to noise that you think contributed to your hearing loss? Yes No Yes Date Signature F262-016-000 Occupational Hearing Loss Questionnaire 06-2015 American LegalNet, Inc. www.FormsWorkFlow.com