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Employment History Hearing Loss F262-013-000 - Washington

Employment History Hearing Loss Form. This is a Washington form and can be used in Claims Workers Comp .
 Fillable pdf Last Modified 3/10/2008
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Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 EMPLOYMENT HISTORY HEARING LOSS Claim Number Start date of first employment Name Please list any BREAK or INTERRUPTION in your work history. We must account for all months since your FIRST START DATE From (Month/Year) To (Month/Year) Reason for work interruption Employment History BEGIN WITH YOUR CURRENT JOB AND LIST ALL PRIOR EMPLOYERS. INCLUDE MILITARY SERVICE. Please start with your most RECENT job and work BACKWARDS. Specify month and year for employment date Employer's Business Name Employer's Address Job Title City Employer's Phone No. From (Month/Year) State To (Month/Year) ZIP + 4 Indicate time exposed to noise in hours per week Describe job duties, type of machinery, tools, material, equipment used, and percentage of time at duties: Were you exposed to loud noise on this job? Yes No If yes, please describe the noise source: Would you describe the noise as continuous? Yes No Or intermittent? hours Yes No How many hours a day were you exposed to this job noise? What kind of ear protection did you use? Other ­ please specify None _______________ ear muffs plastic ear plugs foam ear plugs Date(s) of audiogram(s) Did you have an audiogram while employed by this employer? Yes No I certify that the information is true and correct to the best of my knowledge. Date Signature F262-013-000 hear loss emp hist 3-02 American LegalNet, Inc. www.FormsWorkflow.com
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