Firefighters and Police Officers Hearing Examination Form Name (Last, First, Middle) Sex Date of Examination Address Age Date of Birth Personal Physician's Name Occupation Audiometric Results Frequency in Hertz (Hz), Right Ear 500 1000 2000 3000 4000 6000 8000 500 Frequency in Hertz (Hz), Left Ear 1000 2000 3000 4000 6000 8000 Average of 2K, 3K, and 4K Results: Otoscopic Examination Right Left Normal Appearance Excessive Wax or Debris Abnormal Appearance Average of 2K, 3K, and 4K Results: Remarks RECOMMENDATIONS Medical Referral Retest Recommended Complete Audiogram Audiometer Tester's Name Title Serial Number Tester's Signature Calibration Date Test Date and Time Please sign one copy of this form and submit it to your employer or organization. Employee's Signature Form OD-5 (rev. 06/14) Posted 6/27/14 American LegalNet, Inc. www.FormsWorkFlow.com Date