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

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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.

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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

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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

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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: