Occupational Hearing Conservation Evaluation Report

Report Type: [Baseline Audiogram / Annual Audiogram / Retest-Confirmation / Post-STS Follow-up / Exit Audiogram]

Report Status: [Preliminary – pending professional review / Final]

Test Date/Time: [Date and time of testing]

Employee: [Name] | DOB: [Date of birth] | Employee ID: [ID number] (If any identifier is unavailable, enter "Not provided" rather than leaving blank.)

Employer/Site: [Employer name and site/location]

Job Title: [Job title]

Years in Current Role / Total Years in Noise Exposure: [Years in current role] / [Total years] (If unknown, state "Unknown.")

Examiner: [Name, credentials]

Professional Supervisor: [Name, credentials] (If not assigned or not yet reviewed, state "Not assigned.")

Purpose and Scope

[Brief statement of evaluation purpose, e.g., annual surveillance audiogram with baseline comparison for threshold shift monitoring]

(Include scope limitation: This report documents audiometric results and shift determination for hearing conservation surveillance; it does not constitute a comprehensive diagnostic evaluation, impairment rating, or legal causation determination unless explicitly indicated.)

Occupational and Non-Occupational Exposure History

• Current job noise sources and duration: [Primary noise sources and typical daily exposure duration]
• Controls in place: [Engineering controls] | [Administrative controls]
• Recent noise monitoring: [Date, TWA or dose] (If not provided, state: "Noise monitoring data not provided; exposure based on employee report.")
• Hearing protection devices (HPD): Type(s): [HPD type(s)] | Adherence: [always / often / sometimes / rarely] | Fit/comfort issues: [None / described issues]
• Prior occupational noise exposure: [Prior jobs, military service, approximate duration] (If none or unknown, state accordingly.)
• Non-occupational noise exposure: [Firearms / power tools / loud music / other] | HPD use in these settings: [always / often / sometimes / rarely / never]
• Ototoxic exposures: [Solvents / medications / other] (Only include when directly pertinent to hearing; otherwise omit this line.)

Audiometric and Medical History

• Current symptoms: [Hearing difficulty, tinnitus with laterality/onset, ear pain/fullness/drainage, dizziness] (For routine stable annuals, "No ear symptoms or relevant history reported" is acceptable.)
• Recent loud noise exposure (24–48 hrs): [Yes / No] [Details if yes]
• Relevant otologic history: [Ear infections, surgery, perforations, cerumen issues, other]
• Testing readiness factors: [Congestion / communication or language needs / reliability concerns / none]

Pre-Test Examination

Otoscopy: Right ear – [normal / cerumen / other finding]; Left ear – [normal / cerumen / other finding] (If abnormal, note whether addressed or referred. If otoscopy not part of surveillance protocol, document: "Not performed per program protocol.")

Test Conditions and Equipment

• Frequencies tested: [500, 1000, 2000, 3000, 4000, 6000 Hz; 8000 Hz if performed]
• Masking used: [Yes / No] (If yes, indicate reason.)
• Quiet period: [Required quiet period or HPD substitution observed / not observed] (For annual/retest, note if quiet period was provided.)
• Test environment: Booth/room ID: [ID] | Background noise compliance: [pass / fail] | Date verified: [Date]
• Audiometer: Make/Model or ID: [Device identifier] | Transducer: [Type]
• Calibration: Daily functional check: [Yes / No] on [Date] | Last acoustic/exhaustive calibration: [Date]
• Test reliability: [Good / Fair / Poor] (Note factors affecting validity if applicable. If results are invalid, clearly label and state next step.)

Audiometric Results

(Enter thresholds in dB HL. Use "NR" for no response at maximum output.)

Frequency (Hz)	500	1000	2000	3000	4000	6000	8000
Right Ear (dB HL)	[R500]	[R1000]	[R2000]	[R3000]	[R4000]	[R6000]	[R8000]
Left Ear (dB HL)	[L500]	[L1000]	[L2000]	[L3000]	[L4000]	[L6000]	[L8000]

Brief interpretation: [Hearing within normal limits / high-frequency loss / asymmetric pattern / other configuration] (Do not attribute etiology in this section.)

Baseline Reference and Threshold Shift Calculation

Baseline audiogram date: [Date] | [Original / Revised] (If revised, document date, reason, and ear(s) revised.)

Most recent prior annual: [Date] (If no valid baseline available, state explicitly and recommend establishing baseline per program protocol.)

OSHA Standard Threshold Shift (STS) Calculation

(Calculate using 2000, 3000, and 4000 Hz. Show both uncorrected and age-corrected results if age correction applied.)

Ear	Baseline Thresholds (dB HL)			Current Thresholds (dB HL)			Avg Baseline	Avg Current	Difference (Uncorrected)	Age-Corrected Difference
	2000	3000	4000	2000	3000	4000
Right	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Avg]	[Avg]	[Diff]	[Corrected diff]
Left	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Avg]	[Avg]	[Diff]	[Corrected diff]

Age correction applied: [Yes / No] | Method/table referenced: [Reference source, if applicable]

STS Determination: [Yes / No] | Ear(s): [Right / Left / Bilateral] | Status: [Suspected / Confirmed]

Annual result used: [Initial test / Retest] on [Date] (If retest performed within 30-day window, document outcome.)

NIOSH Significant Threshold Shift: [Yes / No / Not tracked] (If tracked and present, document frequency(ies), ear(s), and retest confirmation.)

Clinical Pattern Interpretation

• Configuration: [Bilateral symmetric / asymmetric / notch pattern / downsloping / flat / other]
• NIHL plausibility: [Pattern consistent with NIHL / Atypical for NIHL] (Note supporting features: notch at 3–6 kHz, symmetry, exposure history. If atypical, note alternative etiologies should be considered and referral may be indicated.)
• Temporary threshold shift consideration: [Recent noise exposure may have contributed / Not suspected] (Include retest strategy if applicable.)

(For clearly normal stable annuals: "Hearing within normal limits bilaterally; no shift from baseline.")

Assessment

1. Hearing conservation surveillance status: Covered worker: [Yes / No] | Current result: [Normal / Abnormal] | STS status: [None / Suspected / Confirmed], [ear-specific if applicable]
2. Standard Threshold Shift (if present): Ear(s): [Right / Left / Bilateral] | Result: [Age-corrected / Uncorrected] | Work-relatedness: [Determined work-related / Determined not work-related / Pending professional review] (Include brief rationale if determined.)
3. Medical concerns (if any): [Significant asymmetry / suspected middle ear pathology / sudden change / severe tinnitus or vertigo / other] (Indicate referral need.)
4. Hearing protection issues (if any): [Non-adherence / poor fit / insufficient attenuation / training needs / none identified]

Counseling and Education Provided

• [Plain-language explanation of results provided to employee]
• [Hearing protection counseling: selection, fit/insertion technique, care; dual protection if indicated]
• [Noise effects education and importance of non-occupational hearing protection]

(For STS or worsening trends, document counseling in detail. For stable normal annuals, "Routine hearing conservation education reinforced" is acceptable.)

Recommendations

To Employee:

• [HPD use requirements per program policy]
• [Retest scheduling if indicated: timeframe and quiet period instructions]
• [Clinical referral if indicated: Audiology / ENT / Primary Care; routine / expedited]
• [Symptom follow-up triggers: sudden hearing change, unilateral tinnitus, vertigo, ear pain/drainage]

To Employer/Hearing Conservation Program:

• [If STS confirmed: Refit/retrain HPD; evaluate protected exposure vs targets; consider engineering/administrative controls]
• [Noise monitoring recommendations if levels unknown or processes changed]
• [Program quality considerations if applicable: HPD variety, training frequency, fit-testing coverage]

Follow-up Plan: [Next annual surveillance date] | [Interim follow-up or retest date if indicated] | [Referrals with urgency level] | [Responsible party for each action]

Notifications and Signatures

Employee notification: Written notification provided: [Yes / No] | Date: [Date] (For STS, OSHA requires written notification within 21 days of determination.)

Examiner signature/date: [Signature and date]

Professional supervisor signature/date: [Signature and date] (Required for problem audiograms and STS determinations.)