West Virginia workers file occupational hearing loss claims on this combined report, which carries the employee's noise-exposure history, the audiologist's test results and the ear specialist's medical opinion. An audiologist and an ENT, otologist or otolaryngologist meet it when evaluating a worker who believes workplace noise caused the loss. The specialist's opinion on cause and the recommended impairment percentage go to the carrier, self-insured employer or TPA administering the claim.
The employee completes Section I: employment history, how and when noise caused the loss, prior hearing loss claims and every doctor seen for ear problems. Section II Part A is completed by the audiologist, and Part B must be completed by an ENT, otologist or otolaryngologist.
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Employees' and Physicians' Report of Occupational Hearing Loss
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The form accepts audiometric results only from an audiologist with a certificate of clinical competence in audiology (CCC-A) or a West Virginia audiology license. That audiologist completes Part A, confirming test agreement and reliability, and an ENT, otologist or otolaryngologist interprets the findings in Part B.
Part B asks for the claimant's noise-exposure employment history and hearing protection use, chief complaints, ICD-10-CM codes, pre-existing conditions, exam results, and whether bilateral sensorineural loss is attributable to or perceptibly aggravated by industrial noise. If it is, give a recommended impairment percentage and explain it.
Yes. By signing Part B, the physician certifies the answers are true, acknowledges responsibilities under West Virginia's workers' compensation law, and agrees to release office notes and test results immediately to the employer or its representative. The physician also lists an FEIN with the practice details.