Nevada > Workers Comp
Firemen Police Officers Hearing Examination Form OD-5 - Nevada
| Firemen Police Officers Hearing Examination Form Form. This is a Nevada form and can be used in Workers Comp . |
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Firemen And Police Officers Hearing Examination Form Name (Last, First, Middle) Sex Date of Examination Address Age Date of Birth Personal Physicians Name Occupation Audiometric Results Frequency in Hertz (Hz), Right Ear Frequency in Hertz (Hz), Left Ear 500 1000 2000 3000 4000 6000 8000 500 1000 2000 3000 4000 6000 8000 Average of 2K, 3K, Average of 2K, 3K, and 4K Results: and 4K Results: Otoscopic Examination Remarks Right Left Normal Appearance Excessive Wax or Debris Abnormal Appearance RECOMMENDATIONS Medical Referral Retest Recommended Complete Audiogram Audiometer Serial Number Calbration Date Testers Name Title Testers Signature Test Date and Time Please sign one copy of this form and submit it to your employer or organization. Employees Signature Date Form OD-5 (rev. 7/99)
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