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-02: Hearing Aid Exception Report
When a WorkSafeNB claimant needs replacement hearing aids or a device outside the Standing Offer Device List, the hearing aid service provider explains the request on this one-page exception report. It records whether the worker is still working, the reason for replacement, the fitting date of the current aid, and the recommended device with the need explained.
Who completes it
The audiologist or hearing aid service provider completes and signs the report with their payee number, and the undersigned 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 report to WorkSafeNB with supporting documents such as manufacturer invoices, a hearing re-evaluation or a full diagnostic hearing assessment, recording the number of attachments and pages.
- Who pays
- WorkSafeNB pays for hearing aids it approves; an Exception Device List upgrade that the worker pays for is recorded as a worker-funded upgrade on Form HA-01.
Good to know
- Reasons for replacement include a significant change in hearing (send the current audiogram), malfunction or inadequate amplification of the current aid, or both.
- For combined hearing change and malfunction, send ANSI results, current ear measurements showing whether targets can be met, and a printout of hearing aid settings.
- Replacement because repair is no longer cost effective applies to aids older than 4 years, with the manufacturer's estimated repair cost entered on the form.
- WorkSafeNB also uses HA-02 as confirmation of the visit if the worker is claiming mileage for it.
Get the official form
Download the current version from the source each time; forms change without notice.
Form HA-02 – Exception Report
Formulaire HA-02 – Rapport d'exception
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.
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Frequently asked questions
When is a WorkSafeNB HA-02 Exception Report required?
Attach it to Form HA-01 when fitting a device from the Exception Device List, and send it for replacement aids or when an aid older than 4 years needs repair. HA-01 also directs providers to HA-02 whenever they need a response from WorkSafeNB.
What should I attach to Form HA-02?
Related documentation such as manufacturer invoices, a hearing re-evaluation or a full diagnostic hearing assessment report. Depending on the reason, send the current audiogram, or ANSI results, current ear measurements and a printout of hearing aid settings, and record the total attachments and pages.
Is Form HA-02 available in French?
Yes. WorkSafeNB's French-language forms list links Formulaire HA-02, Rapport d'exception, as a separate PDF on travailsecuritairenb.ca. The English version is listed for audiologists on the health care forms page, together with Form HA-01 and the Audiometric Report.