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LC - 1 -
WORKSAFENB HEARING LOSS QUESTIONNAIRE
Name: Claim # Date:
PLEASE ANSWER ALL QUESTIONS IN AS MUCH DETAIL AS POSSIBLE.
1) When did you first see a doctor or hearing specialist for your hearing loss?
2) Who did you first see (name of doctor or clinic)?
3) Did your hearing loss start: Gradually? (over time) Suddenly? (all at once)
4) Have you ever had an audiogram (hearing test)? Yes No
If you have answered No, please indicate if you will be having one done. Yes No
(Please note, a certified audiogram is mandatory for the processing of your claim.)
5) If you have had audiograms done, please provide us with the following
information.
Date Name of Doctor, Clinic or Hospital City
6) Do you wear a hearing aid now? Yes No
7) Did you ever see a doctor for other ear problems like infections or injuries?Yes No .
If you answered YES, please indicate the nature of the problem:
Who treated you?
When?
LC - 2 -
HEARING LOSS QUESTIONNAIRE
8) OUTSIDE OF WORK, do you (or did you ever) have loud hobbies or operate
loud power tools or machinery? Yes No
If you answered Yes, please list the loud hobbies or machinery you used.
Check the appropriate box to indicate if you did or did not use hearing
protection.
Name of Hobby, Activity, Machine or Tool Use(d) Hearing Protection?
Yes No
Yes No
Yes No
Yes No
9) Were you ever in any branch of the Canadian or Foreign Armed Forces where
you were exposed to loud noises or firearms? Yes No
If Yes, for how many years of service?
10) Are you currently retired? Yes No
years
If Yes, on what date did you start your retirement?
11) Have you applied for a hearing loss claim with any other Province or
Jurisdiction? Yes No
If Yes, where? (province(s), territory(ies), or state(s)). List all.
NOTICE: You are required to complete the Form B enclosed in this package if you have worked in any other province, territory or state where you were
exposed to noise that could have contributed to your hearing loss.
- 3 -
Name:
WORK HISTORY FORM
Claim # Date:
List all the places you have worked from the time you left school until now.
If there are gaps, please indicate “did not work” for the years that are missing.
Employer City & Province
where you worked
Employment Period Type of Work/Occupation
(List all jobs for each employer and duration of
each job)
Describe the source of noise and the
Exposure period (hours/day)
Hearing
Protection
Was hearing
loss reported to
employer?
From MM/YY
To MM/YY Yes No Yes No
1.
2.
3.
4.
5.
Thank you for completing this questionnaire and please attach extra forms if required.
- 4 -
LC
Form B - Election to Claim Compensation (Interjurisdictional) – Hearing Loss
Name: Claim Number:
Street Address: Telephone Number:
City: Date of Birth:
Province: Postal Code: Social Insurance Number:
I, , suffer from hearing loss that may be the result of
my employment in the following provinces/territories/states:
1. New Brunswick 4.
2. 5.
3. 6.
I must choose whether I will claim compensation under the Workers’ Compensation Act of New
Brunswick or under the law of one of the other provinces/territories/states listed above.
Having considered the matter, I elect to claim compensation for my hearing loss under the
Workers’ Compensation Act of . (your choice of province/territory/state)
If my claim is accepted, I waive and forego any rights to compensation in any other jurisdiction and
will not apply for or accept any benefits from any other jurisdiction unless authorized to do so by the
Board or Commission I elected above.
If my claim is rejected by that Board or Commission, I may then apply for compensation benefits
from one of the other Boards or Commissions.
Worker’s Signature: Date:
Please mail your completed form to: Or fax it toll free to:
WorkSafeNB 1-888-629-4722
P.O. Box 160 Saint John, NB E2L 3X9
- 5 -
Inscription au dépôt direct
Pour recevoir tout paiement de Travail
sécuritaire NB, y compris le remboursement
de dépenses, vous devrez vous inscrire au
dépôt direct.
Pour vous inscrire rapidement, vous n’avez
qu’à aller au portail de Mes services à
l’adresse travailsecuritairenb.ca. Vous pourrez
créer un dossier Mes services et vous inscrire
au dépôt direct de manière instantanée à l’aide
des outils de libre-service.
Si vous voulez vous inscrire au dépôt direct
par courriel ou télécopie, vous devez remplir
le formulaire de dépôt direct de Travail
sécuritaire NB, qui se trouve à l’adresse
travailsecuritairenb.ca (cliquez sur l’onglet
« Travailleurs »). Le formulaire donne les
directives pour la transmission.
Direct Deposit Enrolment
In order to receive any payments, including
expense reimbursements, from WorkSafeNB,
you will need to enrol in direct deposit.
For fast enrolment to direct deposit, please
register for MyServices at worksafenb.ca.
You will be able to create a MyServices
account, and enrol for Direct Deposit
instantly using the self-service tools.
If you wish to enrol in direct deposit via mail or fax, please complete WorkSafeNB’s direct deposit form located at worksafenb.ca under the worker’s section. Instructions for submission are included on the form.
If you have any questions, please call our toll
free number: Si vous avez des questions, vous pouvez nous
téléphoner au numéro sans frais suivant :
1 800 999-9775
1 Portland Street, P.O. Box 160 Saint John,N.B. E2L3X9 Phone 506 632- 2200
Toll-free 1 800 999-9775Fax1 888 629-4722
DIRECT DEPOSIT ENROLMENT FORM Complete all fields unless noted.
* Please sign by hand after the form is completed and printed. Your signature is not required if submitted through secure MyServices email.
LC
PART A – Identification
Last Name Claim Number
First Name Initial(s)
Address
City/Town Province Postal Code
PART B – Banking Information
I’veattachedavoidedchequeor adirectdepositformfrommy I am NOTattaching a voidedcheque. I am providing financial institution (no need to complete banking information below). banking information.
Ifyouattachavoidedchequepleaseclearlywrite“VOID”onthefrontofit.
Branch/Transit # Institution # Account # See page2forhelp finding numbers
5 digits 3 digits 7digits-ifnumberislonger,providelast7digitsonly
Name(s) of Account Holder(s) Financial Inst. Name, Address & Postal Code
(Stamp may be used)
PARTC – Consent
DD/MM/YR
Date Signature*
Provision of the personal information, including your Social Insurance Number (SIN), is pursuant to Department of Public Works and Government Services Act, s. 5, s.11 and the Financial Administration Act, ss. 35(2). The Receiver General will use and disclose information to the federal institutions identified in Part B and to your financial institution to issue direct deposit payments, but will not disclose your SIN to your financial institution. Your personal information will be protected, used and disclosed in accordance with the Privacy Act, and as described in Personal Information Bank PWGSC PSU 712, Receiver General Payments. Under the Act, you have the right to access and correct your personal information, if erroneous or incomplete.
I, the undersigned, have read the privacy notice and consent to the collection, use and disclosure of my personal information as described above.
I authorize WorkSafeNB to deposit my compensation payments into my account by direct deposit. I understand that my acceptance of each amount directly deposited acknowledges entitlement to the benefit or services for which payment is made.
Please inform WorkSafeNB immediately if there is a change in your contact or banking information.
- 6 -
Saint John Office
1-800-999-9775 toll free
506-632-2200 local
1 888 629-4722 fax
Audiometric Report
AUDIOGRAM
RIGHT EAR PURETONE AUDIOGRAM Frequency in hertz 250 500 1000 2000 3000 4000 6000 8000
-10 -10
LEFT EAR PURETONE AUDIOGRAM Frequency in hertz 250 500 1000 2000 3000 4000 6000 8000
-10 -10
0
10
20
30
40
50
60
70
80
90
100
110
0
10
20
30
40
50
60
70
80
90
100
110
0
10
20
30
40
50
60
70
80
90
100
110
0
10
20
30
40
50
60
70
80
90
100
110
When providing the thresholds below, 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.
RIGHT EAR TABULAR AUDIOGRAM LEFT EAR TABULAR AUDIOGRAM
Hz 500 1000 2000 3000 500 1000 2000 3000
Air
Bone
WORKER INFORMATION
Worker’s Last Name: First Name: Initial: Date of Birth: dd l mm l yyyy
HEALTH CARE PROVIDER INFORMATION
Provider Name: ID#:
Completed by: Date Reported: dd l mm l yyyy Phone:
WCB Claim #:
Health Card #:
Key to AudiometricSymbols
O = right unmasked air
X = left unmasked air
= right masked air
< = right unmasked bone
> = left unmasked bone
[ = right masked bone
] = left masked bone
C = contralateral reflex
I = ipsilateral reflex
Th
resh
old
in D
ec
ibe
ls (d
BH
L)
Th
resh
old
in D
ec
ibe
ls (d
BH
L)
SPEECH AUDIOMETRY
Right Left
PTA
.5K, 1K, 2K
SRT dB SN L dB dB SN R dB
WRS
Live
CD
at %
dB
SN L dB
at %
dB
SN R dB
at %
dB
SN L dB
at %
dB
SN R dB
MCL
UCL
Otoscopy
TYMPANOGRAM (mandatory for Audiologist Diagnostic Assessment)
MEP daPa ECV ml SC ml Type
RE
LE
ACOUSTIC REFLEXES (mandatory for Audiologist Diagnostic Assessment)
Ipsi re
fle
x C
on
tra
re
fle
x th
resh
old
th
resh
old
Sti
mu
lus e
ar
HTL Earphones:
Supra-aural
Insert
Audiometer:
Calibrated:
dd l mm l yyyy
.5K 1K 2K 4k
RE Reliability: GoodLE
Booth:
Yes
No
RE Fair
PoorLE
- 7-
AUDIOLOGIC ASSESSMENT
Audiometry
Yes No SRT vs. PTA (.5k, 1k, 2k, OR .5k, 1k AVG.) ± 7-10 dB
Yes No Tympanometry agrees with nature of hearing loss
Yes No Acoustic reflexes as anticipated for nature and degree of
hearing loss
If NO to any of the above, provide details:
Test Behaviours
Yes No Atypical response patterns
Yes No Test inconsistency
Yes No Unusualspeechaudiometric patterns orresponses
Yes No Discrepancy between history, thresholds and/or
behaviours outside test booth
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
MEDICAL INFORMATION
Other relevant history reported (if
yes provide details): Yes No Right Left Details
Tinnitus
Otalgia
Otorrhea
Dizziness/imbalance
Facial numbness
Head injury
Familial hearing loss
Chronic disease eg diabetes, etc
Medications
Meniere’s
Ear or cranio facial surgery
NOISE EXPOSURE, ONSET AND PROGRESSION
Yes No Don’t know
Type of noise exposure:
Broadband noise exposure
Tonal noise exposure
Intensity of noise exposure: Lex dBA
Duration of noise exposure: Daily hours Annually hours
Are early audiograms available for review?
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 YES please submit the earlier audiograms as support.
If NO to any of the above, please explain:
Has there been any non-occupational noise exposure? If yes, please provide details:
WCB Claim #: - 8 -
CURRENT AUDIOMETRIC RESULTS
Yes No
Do low frequency thresholds (250Hz-1000Hz) exceed 40dBHL?
Do high frequency thresholds (3000Hz-8000Hz) exceed 75dBHL?
Is the hearing loss asymmetrical (> 15 dB difference)?
If YES to any of the above, please explain:
Please confirm that you have shared the results of this test with worker Yes No
SUMMARY CLINICAL IMPRESSION
Provide details:
WCB Claim #:
- 9 -
- 10 -
Worker’s Name: Claim #
- IMPORTANT-
Once you have completed all the necessary forms we have enclosed, please respond to
the statements below and return this page with your documentation.
1) I am returning a completed and signed claim application – Form 67 - Report of
Accident or Occupational Disease: Yes No
2) I am returning a completed Hearing Loss Questionnaire: Yes No
3) I am returning a completed Work History Form: Yes No
If you want to provide more information than the Work History form has asked you
for, or has room for, please use an extra page.
4) I am returning a completed and signed Form B because part of my work was
outside of New Brunswick: Yes No
5) I have entered my direct deposit information on MyServices, or I have included my
direct deposit information: Yes No
6) I have provided you with my audiometric report and first certified audiogram and
my most recent certified audiogram: Yes No
If you have answered no, please indicate why:
- IMPORTANT REMINDER -
MISSING INFORMATION OR FORMS WILL CAUSE YOUR CLAIM TO BE
DELAYED OR REJECTED.
PLEASE sign and date this form if you agree with the following statement:
“The information I am sending is as correct and as complete as I am able to offer, and
I have made every reasonable effort to provide all that WorkSafeNB has asked for.”
Worker’s Signature: _Date:
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