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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.

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?

If you answered 'Yes'

8. Do you wear a shoulder-mounted speaker?

If you answered 'Yes'

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

If you answered 'Yes'

10. Do you work a noisy second job?

11. Have you served in the military?

If you answered 'Yes'

12. Do you discharge firearms?

If you answered 'Yes'

13. Are you left- or right-handed?

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? Duration of activity per week/month/year
Metalwork/Grinding
Chainsaw/Chipper
Air tools
Farm implements
Leaf blower/Lawn mower
Loud cars/boats/motorcycles/racing
Aviation
Music/Concerts
Music device (e.g., iPod)
If Yes, which ear was most affected?

Additional information

Signature

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