Audiologists and hearing instrument specialists record a WSIB patient's hearing test on this four-page form for an initial noise-induced hearing loss claim, a hearing aid replacement request or a subsequent test. It captures the medical case history, pure-tone and speech audiometry for both ears, otoscopy, tympanometry and acoustic reflexes. The WSIB asks for it as part of the patient's initial hearing loss claim submission.
The audiologist or hearing instrument specialist who performed the testing completes the whole form, and their name, signature and qualifications must be clearly shown. The clinic must confirm that person is in good standing with their regulatory college or professional association.
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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Air conduction thresholds for both ears at 250, 500, 1000, 2000, 4000 and 8000 Hz, plus 3000 Hz, with 750, 1500 and 6000 Hz added when there is a 20 dB difference between octaves. Bone conduction covers 250 to 4000 Hz, including 3000 Hz, with masking as needed. Both the graphs and the written thresholds must be completed.
The form covers an initial assessment, a replacement request and subsequent tests. For a replacement within the five-year cycle, a prescription and a completed hearing assessment must accompany the request, and audiogram reports must be submitted within six months of the hearing test. For a mini bundle, send the new prescription and hearing assessment with the request.
Yes. The French version is Évaluation audiologique (3275B), and the English form notes that it is available in French. Whichever version you use, list the years of all audiogram tests in the claim file, attach previous audiograms with their dates and upload the form through wsib.ca/submit.