Employee Audiogram form - Alberta.ca...physician for review as required by the Occupational Health...

2019 Employee Audiogram

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AUDIOGRAMS MUST BE COMPLETED ON THIS FORM.

ALL INVOICES MUST BE SUBMITTED TO THE EMPLOYEE’S DEPARTMENT. (Do not submit with the audiogram)

Failure to use the proper form or submit the invoice to the employee’s department, will result in payment delay.

PART 1 – Employee Information: (To be completed by Employee)

Last Name: First Name:

GoA Employee ID: Birth Date (yyyy-mm-dd):

Department/Ministry: Family Physician:

Employee Release Information: I hereby authorize the Audiologist/Technicians to release my audiogram test results to Wellness, Health & Safety - Public Service Commission, to be entered in the Occupational Health Tracking System and to be forwarded to the designated physician for review as required by the Occupational Health and Safety Code. Additionally, I authorize Wellness, Health & Safety - Public Service Commission to release my industrial hearing screening categories to Human Resources – Public Service Commission.

___________________________________________ ___________________________________________ Employee Signature (Required) Date (yyyy-mm-dd)

PART 2 – Service Provider Information:

Full Name of Technician (Last Name, First Name):

Service Provider Phone Number:

Test Date (yyyy-mm-dd): Test Time (24 HR):

Test Location: Unknown Permanent Sound Booth Mobile Sound Booth Mobile Other

Audiometer Model: Calibration date of Audiometer (yyyy-mm-dd):

PART 3 – Employee Medical History:

Dizziness Yes No Unknown Comments:

Ear Specialist Yes No Unknown Comments:

Head Injury Yes No Unknown Comments:

Loud Blast Yes No Unknown Comments:

Medications Yes No Unknown Comments:

Other Infection Yes No Unknown Comments:

PART 4 – Otological History/Symptoms:

Bleeding None Both Left Right Unknown Comments:

Discharge None Both Left Right Unknown Comments:

Ear Drum None Both Left Right Unknown Comments:

Ear Infection None Both Left Right Unknown Comments:

Ear Surgery None Both Left Right Unknown Comments:

Pain None Both Left Right Unknown Comments:

Pressure None Both Left Right Unknown Comments:

Tinnitus None Both Left Right Unknown Comments:

https://www.alberta.ca/index.aspx


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PART 5 – Employee Noise Exposure:

Work Exposure: _______hours per week Protection worn: _______%

Specify examples of exposure:

Protection Used: (check all that apply)

None Earmuffs Earplugs Other: ____________________

Recreational Exposure: _______ hours per week Protection worn: _______%

Specify examples of exposure:

Protection Used: (check all that apply)

None Earmuffs Earplugs Other: ____________________

PART 6 – Employee Test Results

Hours Away from Noise Prior to Testing: < 14 hours 14 – 24 hours > 24 hours

PART 7 – Important Message to the Service provider:

1. The Person named above authorises disclosure of medical information to Wellness, Health & Safety - Public Service

Commission (PSC). It will be used in connection with the administration of the Occupational Health Program.

2. The service provider may be contacted to provide additional information.

3. Service provider can receive a basic fee for completing this report. Payment will be made to service provider upon

receipt of invoice to the Employee’s Department. (Do not submit with the audiogram)

4. Audiogram MUST be fully completed on this form, failure to do so, may result in payment delay.

Test Results Explained to Employee Copy of Test Results Given to Employee

___________________________________________ ___________________________________________ Audiologist/Technician Signature Date (yyyy-mm-dd)

Service Provider Address (Stamp or Print) Ensure Postal Code is included



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Please return this confidential form to:

Mailing Address: Occupational Health Tracking Program Coordinator Wellness, Health & Safety - Public Service Commission 5th Floor, Peace Hills Trust Tower, 10011 – 109 Street Edmonton, AB T5J 3S8

FAX: 1 (780) 415-9438

E-mail: [email protected]

NOTE: The personal information provided on this form is collected under the authority of the Government Organization Act (RSA 2000) and managed in

accordance with the Freedom of Information and Protection of Privacy Act (RSA 2000). The information will be used for the purpose of administering the Noise

Management component of the Occupational Health and Safety Program.


mailto:[email protected]

Employee Audiogram form - Alberta.ca...physician for review as required by the Occupational Health...

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