Employment History Hearing Loss {F262-013-000}

Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 Employment History ­ Hearing Loss Claim Number Start Date of First Employment Name Breaks in Employment History 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. Specify month and year for employment dates. Employer Name Employer Address Job Title From (Month/Year) To (Month/Year) Phone Number City State Zip Code Indicate Time Exposed to Noise in Hours per Week Describe job duties; type of machinery, tools, materials, and equipment used; and percentage of time at duties: Were you exposed to loud noise on this job? Yes No If yes, describe the noise source: _____________________________________________________________ Would you describe the noise as: Continuous Intermittent How many hours a day were you exposed to this job noise? ____________ hours What kind of ear protection did you use? None Ear Muffs Plastic Ear Plugs Foam Ear Plugs Other:______________________ Did you have an audiogram while working for this employer? Yes No If yes, date(s) of audiogram(s):_______________________________________________________________ I certify that the information is true and correct to the best of my knowledge. Signature Date F262-013-000 Employment History ­ Hearing Loss 06-2015 American LegalNet, Inc. www.FormsWorkFlow.com If additional sheets are needed, copy this page. Begin with current job and list all prior employers including military service. Claim Number Name Employer Name Employer Address Job Title From (Month/Year) Start Date of First Employment Phone Number City To (Month/Year) State Zip Code Indicate Time Exposed to Noise in Hours per Week Describe job duties; type of machinery, tools, materials, and equipment used; and percentage of time at duties: Were you exposed to loud noise on this job? Yes No If yes, describe the noise source: _____________________________________________________________ Would you describe the noise as: Continuous Intermittent How many hours a day were you exposed to this job noise? ____________ hours What kind of ear protection did you use? None Ear Muffs Plastic Ear Plugs Foam Ear Plugs Other:______________________ Did you have an audiogram while working for this employer? Yes No If yes, date(s) of audiogram(s):_______________________________________________________________ Employer Name Employer Address Job Title From (Month/Year) Phone Number City To (Month/Year) State Zip Code Indicate Time Exposed to Noise in Hours per Week Describe job duties; type of machinery, tools, materials, and equipment used; and percentage of time at duties: Were you exposed to loud noise on this job? Yes No If yes, describe the noise source: _____________________________________________________________ Would you describe the noise as: Continuous Intermittent How many hours a day were you exposed to this job noise? ____________ hours What kind of ear protection did you use? None Ear Muffs Plastic Ear Plugs Foam Ear Plugs Other:______________________ Did you have an audiogram while working for this employer? Yes No If yes, date(s) of audiogram(s):_______________________________________________________________ I certify that the information is true and correct to the best of my knowledge. Signature Date F262-013-000 Employment History ­ Hearing Loss 06-2015 American LegalNet, Inc. www.FormsWorkFlow.com