Rapport audiometrique
Audiogram and audiometric findings for an occupational hearing loss claim.
- Completed by
- Audiologist
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
WorkSafeNB Form HA-01: Hearing Aid Fitting and Service
Hearing aid service providers use this one-page report to tell WorkSafeNB what they did at a claimant's visit. It covers fittings from the Standing Offer or Exception Device List, worker-funded upgrades, supplies such as batteries, tubing and wax guards, maintenance and services, in-house and manufacturer repairs, and other reasons for the visit.
Who completes it
The audiologist or hearing aid service provider completes and signs the form with their payee number. For repairs, the undersigned also declares that the requested service is not the result of abuse or negligence by the worker.
Submitting and payment
- How to submit it
- Fax or mail the form to WorkSafeNB with related documents such as manufacturer invoices or hearing assessment reports, recording the number of attachments and pages.
- Who pays
- WorkSafeNB pays the service provider, identified by payee number, for covered services; batteries are billed with an invoice, and manufacturer repair costs and repair charges are entered on the form.
Good to know
- A fitting from the Exception Device List needs Form HA-02, the Exception Report, completed and attached.
- Manufacturer repairs on this form are for hearing aids less than 4 years old; for older aids, send Form HA-02.
- If the worker is claiming mileage for the visit, WorkSafeNB also uses this form as confirmation of the visit.
- HA-01 is not the route for a reply: if you need a response from WorkSafeNB, the form says to use HA-02.
Get the official form
Download the current version from the source each time; forms change without notice.
Form HA-01 – Hearing Aid Fitting and Service Report
Formulaire HA-01 – Rapport sur l'ajustement et le service relatifs à un appareil auditif
Fill it with Vero
Upload the fillable PDF 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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
When do I use HA-01 instead of HA-02?
Use HA-01 to report Standing Offer Device List fittings, supplies, maintenance and repairs on aids under 4 years old. Use HA-02 for Exception Device List fittings, replacement aids, aids over 4 years old, or whenever you need a response from WorkSafeNB.
Is Form HA-01 available in French?
Yes. WorkSafeNB's French-language forms list links a French version titled Formulaire HA-01, Rapport sur l'ajustement et le service relatifs à un appareil auditif. The English version is listed for audiologists on WorkSafeNB's health care forms page.