Vendor's purchase order requisition for hearing aid products or services on a claim.
- Completed by
- Hearing aid vendor (audiologist or hearing instrument practitioner)
- Issued by
- WorkplaceNL
- Format
- Language
- English
WorkplaceNL Audiologist's Report (Form AR)
A worker making a hearing loss claim to WorkplaceNL must first have an assessment by a registered audiologist, with no WorkplaceNL referral needed. The audiologist then sends this one-page report with the worker's audiogram. It covers equipment calibration, onset and type of loss, relevant history, audiometry crosschecks, test behaviours and a cause-effect analysis of noise-induced loss.
Who completes it
The audiologist completes the report, including worker and employer details, and certifies that they performed both the assessment and the form. The worker separately completes the Hearing Loss Worker's Report (Form 6HL).
Submitting and payment
- How to submit it
- The form says to send it by fax only, with the worker's audiogram attached.
- Who pays
- WorkplaceNL pays a reporting fee when you tick that one is requested, but only if an audiogram is attached, and you certify that no prior payment was received for the visit.
Good to know
- Confirm that the equipment was biologically calibrated on the day of the assessment and electroacoustically calibrated within the last 12 months.
- Crosschecks include SRT against the pure-tone average within 7 to 10 dB, inter-octaves where needed including 3000 Hz, a reliability statement, and 16 hours free of hazardous noise.
- The cause-effect section, which excludes traumatic hearing loss, asks about SNHL, loss in the 3000 to 6000 Hz region, thresholds of 75 dB HL or more, and progression on older audiograms.
- WorkplaceNL's Form 6HL says an audiologist's report must accompany every occupational hearing loss application; the AR form is dated July 2016.
Get the official form
Download the current version from the source each time; forms change without notice.
Audiologist's Report (AR)
Fill it with Vero
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Frequently asked questions
Does a worker need a WorkplaceNL referral for a hearing assessment?
No. WorkplaceNL says a worker submitting a hearing loss claim must first have an audiology assessment by a registered audiologist, and does not need a referral from WorkplaceNL for it. The audiologist then completes the Audiologist's Report (Form AR) and submits it with the worker's audiogram.
When is the Audiologist's Report reporting fee paid?
Section A asks whether a reporting fee is requested, and the form states that a reporting fee will only be paid if an audiogram is attached. The signature section certifies that the report is complete and accurate and that no prior payment was received from WorkplaceNL for the visit.
What history does the WorkplaceNL Audiologist's Report ask for?
Onset and type of hearing loss, whether this is the initial visit, and other relevant history: tinnitus with side, pattern and years, otalgia, otorrhea, dizziness or imbalance, facial numbness, head injury, familial hearing loss, chronic disease and medications. The worker's own report of stable or slowly progressing loss is also recorded.