Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 Employment History 226 Hearing Loss Claim Number Name Start Date of First Employment Breaks in Employment History Please list any break or interruption in your work history. We must account for all months since your first start date. From (Month/Year) To (Month/Year) Reason for Work Interruption Employment History Begin with your current job and list all prior employers. Include military service. Specify month and year for employment dates. Employer Name Phone Number Employer Address City State Zip Code Job Title From (Month/Year) To (Month/Year) Indicate Time Exposed to Noise in Hours per Week Describe job duties; type of machinery, tools, materials, and equipment used; and percentage of time at duties: Were you exposed to loud noise on this job? Yes No If yes, describe the noise source: Would you describe the noise as: Continuous Intermittent How many hours a day were you exposed to this job noise? hours What kind of ear protection did you use? None Ear Muffs Plastic Ear Plugs Foam Ear Plugs Other: Did you have an audiogram while working for this employer? Yes No If yes, date(s) of audiogram(s): I certify that the information is true and correct to the best of my knowledge. Signature Date F262-013-000 Employment History 226 Hearing Loss 06-2015 American LegalNet, Inc. www.FormsWorkFlow.com If additional sheets are needed, copy this page. Begin with current job and list all prior employers including military service. Claim Number Name Start Date of First Employment Employer Name Phone Number Employer Address City State Zip Code Job Title From (Month/Year) To (Month/Year) Indicate Time Exposed to Noise in Hours per Week Describe job duties; type of machinery, tools, materials, and equipment used; and percentage of time at duties: Were you exposed to loud noise on this job? Yes No If yes, describe the noise source: Would you describe the noise as: Continuous Intermittent How many hours a day were you exposed to this job noise? hours What kind of ear protection did you use? None Ear Muffs Plastic Ear Plugs Foam Ear Plugs Other: Did you have an audiogram while working for this employer? Yes No If yes, date(s) of audiogram(s): Employer Name Phone Number Employer Address City State Zip Code Job Title From (Month/Year) To (Month/Year) Indicate Time Exposed to Noise in Hours per Week Describe job duties; type of machinery, tools, materials, and equipment used; and percentage of time at duties: Were you exposed to loud noise on this job? Yes No If yes, describe the noise source: Would you describe the noise as: Continuous Intermittent How many hours a day were you exposed to this job noise? hours What kind of ear protection did you use? None Ear Muffs Plastic Ear Plugs Foam Ear Plugs Other: Did you have an audiogram while working for this employer? Yes No If yes, date(s) of audiogram(s): I certify that the information is true and correct to the best of my knowledge. Signature Date F262-013-000 Employment History 226 Hearing Loss 06-2015 American LegalNet, Inc. www.FormsWorkFlow.com