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WorkSafeNB Audiometric Report (Hearing Loss Claim)

For an occupational hearing loss claim, WorkSafeNB asks the audiologist to record test results on this three-page fillable report. It covers otoscopy, speech audiometry, tympanometry, acoustic reflexes and right and left pure-tone audiograms, then classifies the degree and type of loss and middle ear function for each ear and asks whether the history fits noise-induced loss.

Who completes it

The audiologist completes the whole report, entering the provider name and number, who completed it and the date reported. The worker files a separate Application for Benefits Occupational Hearing Loss and the employer an Employer Report of Occupational Hearing Loss.

Submitting and payment

How to submit it
Send it to WorkSafeNB through MyServices, by toll-free fax or by mail; if you fax a form, don't mail it as well. Save the fillable PDF to your computer before you start, as the form warns that information can otherwise be lost.
Who pays
WorkSafeNB is responsible for payments for treatment covered under New Brunswick's Workers' Compensation Act, but this report has no billing section, so ask WorkSafeNB how to invoice the assessment.

Good to know

  • Confirm that the worker was reportedly free of hazardous noise exposure for 16 hours immediately before the assessment; the report asks this directly.
  • Enter air conduction thresholds if the loss is sensorineural, and add bone conduction thresholds only if the loss is conductive or mixed.
  • The noise-exposure questions ask whether loss developed in the first 10 to 15 years of exposure, began as a 3000 to 6000 Hz notch, and is symmetrical within 15 dB.
  • Submit any early audiograms or ENT consultations available for review, and give details of any non-occupational noise exposure.

Get the official form

Download the current version from the source each time; forms change without notice.

Audiometric Report

Rapport audiometrique

Official pagePDFVersion française

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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

What does WorkSafeNB ask about test reliability on the audiometric report?

The audiologic assessment asks whether SRT agrees with the pure-tone average within 7 to 10 dB and whether tympanometry and acoustic reflexes fit the loss. It also flags atypical response patterns, test inconsistency, unusual speech responses, and any discrepancy between history, thresholds and behaviour outside the booth.

How is hearing loss graded on the WorkSafeNB report?

Each ear is classed as normal (0 to 15 dBHL), minimal (16 to 25), mild (26 to 40), moderate (41 to 55), moderate-severe (56 to 70), severe (71 to 90) or profound (91 and above). Type of loss and middle ear function are recorded separately for the right and left ear.

Is the WorkSafeNB Audiometric Report available in French?

Yes. WorkSafeNB publishes a French version of the report on its French-language site, travailsecuritairenb.ca. The English version is listed for audiologists on WorkSafeNB's health care forms page, alongside the hearing aid forms HA-01 and HA-02.