WORKERS' COMPENSATION BOARD STATE OF NEW YORK RECORD OF PERCENTAGE HEARING LOSS This form is only to be used to calculate and report percentage hearing loss in cases of OCCUPATIONAL LOSS OF HEARING pursuant to Workers' Compensation Law Section 49-gg. For measurement of traumatic loss of hearing, see the Board's Medical Guidelines (2012). Claimant______________________________ WCB Case No.__________________________ RIGHT EAR Hearing Levels at Frequencies of 500 Hz 1,000 Hz 2,000 Hz 3,000 Hz NOTE Test No. 500 Hz. frequency is to be used only when the claimant's date of disablement is on or after January 1, 1984. Name and Model Number of Audiometer LEFT EAR Hearing Levels at Frequencies of 500 Hz 1,000 Hz 2,000 Hz 3,000 Hz A. 1 Audiometer Standardized ISO (ANSI) db. db. db. db. db. db. db. db. B. *2 Audiometer Standardized ISO (ANSI) db. db. db. db. db. db. db. db. C. D. *3 Audiometer Standardized ISO (ANSI) db. db. db. db. db. db. db. db. If more than one test is given, the lowest at each Frequency Average of Hearing Levels indicated in item A (if one test) or item D (if more than one) Adjusted Hearing Loss, In Decibels (Line E minus 25 db.) Adjusted Hearing Loss, In Percentage (Line F times 1 1/2) db. db. db. db. db. db. db. db. E. db. db. F. db. minus 25 db. is db. db. minus 25 db. is db. G. times 1 1/2 is % times 1 1/2 is % Percent of Binaural Hearing Loss Lower % Higher% ________________% ________________% times 5 equals _______________% times 1 equals _______________% TOTAL PERCENT................................................................................______________% Binaural Loss in Percentage Date of Test No. 1 ( Total . 6 . ) ______________% Date of Test No. 3* Date of Test No. 2* *Internal test consistency and professional judgment should determine whether a second or third test battery or other more extensive forms of testing may be necessary. Where more extensive forms of testing are necessary, submit a narrative report. C E R T I F I C AT I O N I hereby certify that the audiomatic test was performed with an audiometer having specifications as prescribed by the American National Standards Institute, S3.6-1969, Specifications for Audiometers, and in a room whose background noise meets the requirements of the latest revision of the American National Standards Institute, S3.1-1960, Criteria for Background Noise in Audiometer Rooms. Audiometer calibrated at least once annually. Signature ____________________________________ Date__________________ Telephone No.____________________________ HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information. C-72.1 (1-12) American LegalNet, Inc. www.FormsWorkFlow.com