Otolaryngologists use this one-page WSIB report after seeing a patient with hearing loss, tinnitus, dizziness or balance complaints, most often in a noise-induced hearing loss claim. It records occupational and recreational noise exposure, an ear examination, audiogram results and your diagnosis. Related forms are the worker's report on work-related noise-induced hearing loss (0032A) and the hearing assessment (3275A).
The otolaryngologist (ENT specialist) completes the whole form, including the billing section, and signs it or ticks the electronic-signature box and types their name and the date. The worker files their own report on work-related noise-induced hearing loss (0032A) separately.
Download the current version from the source each time; forms change without notice.
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.
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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It asks for the patient's type of work, use of hearing protection and number of years of exposure, plus noisy hobbies or activities such as hunting or snowmobiling. For gun use it records the type, number of years, which shoulder and rounds per year. Ototoxic medications, head injuries, family history, allergies and ear surgery are also flagged.
The service code printed on the form is M647, the consultation report code, which the fee schedule says is billed only with a consultation visit. Fee code M650 is printed below the billing section for enclosed copies of previous consultation reports or audiograms. Add your WSIB provider number, invoice number and any HST details.
Yes. The WSIB publishes a French version, Rapport de consultation ORL (1787B), and the English form notes that it is available in French. Whichever version you use, save the completed form and upload it with the audiograms and previous reports through WSIB online services at wsib.ca/submit.