Customers MyTKGroup Forms Service Checklist

Extended Questionnaire for Work-Relatedness Determination

Before using this form, your safety coordinator must obtain a reference code from T K Group.

Don't have a code? Your safety coordinator may apply for one. Apply for Reference Code

This questionnaire is for an OSHA recordable hearing loss determination.

Instructions for this questionnaire:
1. Please answer all questions.
2. If any item needs clarification, include the explanation in the additional information section at the end.

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Reference Code

Name

Company

Company Location Name

Assessed Noise Exposure (TWA)

Shift Duration

1. What type of hearing protectors do you use at work?

2. If known, what is the labelled attenuation (NRR) of your protectors?

3. What percentage of the time do you wear hearing protectors at work when exposed to noise?

6. Do you work with any of the following chemicals?

Toluene
- Yes
- No
Xylene
- Yes
- No
Styrene
- Yes
- No
Methyl Ethyl Ketone (MEK)
- Yes
- No

7. Do you work in noise coming from one side?

If you answered 'Yes'

Which ear is most affected?

Left Ear
Right Ear

8. Do you wear a shoulder-mounted speaker?

If you answered 'Yes'

Which position of the speak best applies?

Closer to Left ear
Closer to Right ear
Positioned on Center of chest

9. Have you been exposed to a work-related blast?

If you answered 'Yes'

Which ear was most affected?

Left Ear
Right Ear

10. Do you work a noisy second job?

11. Have you served in the military?

If you answered 'Yes'

Dates of service

Branch

Were you noise-exposed?

Did you wear hearing protection?

12. Do you discharge firearms?

If you answered 'Yes'

What types of firearms?

How many rounds per year?

What type of shooting?

Hunting
Target
Both

Do you wear hearing protection?

Yes
No
Varies

13. Are you left- or right-handed?

Left
Right

14. Indicate the off-the-job activities you engage in.

Off-The-Job Activity	Do you engage in activity?	Do you use hearing protection when performing activity?
Metalwork/Grinding	Yes No	Yes No Varies
Chainsaw/Chipper	Yes No	Yes No Varies
Air tools	Yes No	Yes No Varies
Farm implements	Yes No	Yes No Varies
Leaf blower/Lawn mower	Yes No	Yes No Varies
Loud cars/boats/motorcycles/racing	Yes No	Yes No Varies
Aviation	Yes No	Yes No Varies
Music/Concerts	Yes No	Yes No Varies
Music device (e.g., iPod)	Yes No	If Yes, which ear was most affected? Left Ear Right Ear Both

Additional information

Signature

(Click and drag in rectangle below to draw)

Extended Questionnaire for Work-Relatedness Determination

4. Do you currently have any of the following ear-related complaints?

5. Have you been diagnosed by a physician with any of the following?

6. Do you work with any of the following chemicals?

7. Do you work in noise coming from one side?

8. Do you wear a shoulder-mounted speaker?

9. Have you been exposed to a work-related blast?

10. Do you work a noisy second job?

11. Have you served in the military?

12. Do you discharge firearms?

13. Are you left- or right-handed?

14. Indicate the off-the-job activities you engage in.

Additional information

Signature