CA-1332 Outline for Otologic Testing

O utline for Otologic Evaluation U.S. Department of Labor

Employment Standards Administration

Office of Workers’ Compensation Programs

Division of Federal Employees' Compensation

	OMB No. 1215-0103 Expires: 10-31-08
NAME:      
FILE NUMBER:      
I. HISTORY: (A) Our adjudication and possible awards are based solely on the fact of causality of all or a portion of the loss arising from exposure related to Federal Civilian employment. The only history of noise exposure on which this case can be legitimately adjudicated is that defined by the Statement of Accepted Facts. If there is any variance in the history as given by the patient and that contained in the Statement of Accepted Facts, it should be carefully considered and commented upon, but the opinion you render must be based solely on the Statement of Accepted Facts. IS THERE ANY SIGNIFICANT VARIATION FROM THE STATEMENT OF ACCEPTED FACTS? (B) Please comment on this patient's hearing at the beginning of his/her significant noise exposure in Federal Civilian employment, if audiometric data is available. (C) Compare, if possible, the present audiometric findings to those at the beginning of exposure. Does this individual show a sensorineural loss that is in excess of what would be normally prediated on the basis of presbycusus? (D) Was the workplace exposure, as described in the material provided, sufficient as to intensity and duration to have caused the loss in question? (E) Please provide all other relevant history facts, (such as other noise exposure) emotional disorders, sysmetic diseases, (such as diabetes) local infections, ototoxic drug usage, surgery, etc. as they relate to this individual's hearing loss sensorineural or conductive.
Public Burden Statement (pl 99-500) Public reporting burden for this collection of information is estimated to vary from 15 to 45 minutes per response with an average of 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Information Management, Department of Labor, Room N-1301, 200 Constitution Avenue, NW, Washington, DC 20210; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503. Privacy Act The authority for requesting the following information is 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to benefits. Furnishing the requested information is required to obtain or retain a benefit. Information collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974, as amended (5 U.S.C. 552a). Failure to furnish the requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

CA-1332

Rev. July 1988

II. PHYSICAL EXAM Please make this as extensive as necessary in line with any findings bearing on this individual's hearing loss. If only a minimal note is required, please include at least the following: Describe the canals and drums. Drum Motility: Result of Basic fork tests: Is there indication of any medical condition such as an acoustic neuroma or meniere's disease? Please explain. Other: III. OPINION DIAGNOSIS:
If sensorineural or mixed, complete the following: The sensorineural hearing loss seen is, in part or all, in my opinion DUE NOT DUE
to noise exposure encountered in this claimant's Federal civilian employment. Medical rationale supporting the above position: Recommendations: Signature of Physician ______________________________________________

IV. VERIFICATION OF AUDIOMETRIC TESTING

Audiologist's Name ___________________________________________________________

AUDIOGRAM IS ONLY ACCEPTABLE FOR USE IF AUDIOLOGIST IS AHSA CERTIFIED OR HAS A STATE LICENSE - REFER FOR TESTING IF OFFICE AUDIOLOGIST DOES NOT MEET THIS CRITERIA.

ASHA Cert. I.D. ____________________________ State License I.D. _____________________________

Audiometer:

Manufacturer _______________________ Model ________________________ Serial No. ______________________

Type (manual, automatic, microprocessor) __________________________________________________________

CALIBRATION (BN. NO. 82-18 requires annual calibration to ANSI 1969 Standards)

Date Calibrated : Month _______________________ Day ______________________ Year ____________________

By Whom _______________________________________________________________________

The audiometric test results are valid and representative of this employee's hearing sensitivity.

Yes No

If you have reservations concerning the audiometric test findings, please state what additional evaluations or tests you would suggest.

BOTH SIGNATURES ARE REQUIRED. IF THE OPINIONS VARY, PLEASE ATTACH A SIGNED SHEET WITH EXPLICATIVE RATIONALE.

Signature __________________________ Audiologist

Signature __________________________ Physician

Please note the following points which are commonly missed and without which adjudication cannot be completed.

(1) Please include your complete audiograms with air conduction thresholds between 500 and 8000 Hz. and bone conduction thresholds between 500 and 4000 Hz. Please include impedance audiometry.

(2) Be sure the audiologist is state licensed, or certified in audiology by the American Speech Language Hearing Association.

(3) Be sure all opinions are completed and signed by the appropriate individuals.

V. AUDIOMETRIC TEST RESULTS: TO ELIMINATE THE POSSIBILITY OF TEMPORARY THRESHOLD SHIFT, THE PATIENT SHOULD NOT BE TESTED UNLESS FREE OF SIGNFICIANT NOISE EXPOSURE FOR AT LEAST 16 HOURS - OTHERWISE RESCHEDULE. PATIENT FREE FROM NOISE EXPOSURE FOR _________ HOURS PRIOR TO TESTING. Audiometric testing completed on ___________ at ___________ (date) (hour) Pure-tone Audiometry (please also include your complete audiograms with air conduction threshold from 500 through 8000 Hz; bone conduction from 500 through 4000 Hz; and the tympanogram, acoustic reflexes and/or other impedance testing.) * Is a significant air-bone gap present? Right - Yes ( ) No ( ) Left - Yes ( ) No ( )
	Right Ear				Left Ear
	AIR	BONE		AIR			BONE
500 Hz	____ dB	____ dB		____ dB			____ dB
1000 Hz	____ dB	____ dB		____ dB			____ dB
2000 Hz	____ dB	____ dB		____ dB			____ dB
3000 Hz	____ dB	____ dB		____ dB			____ dB
4000 Hz	____ dB	____ dB		____ dB			____ dB
6000 Hz	____ dB			____ dB
8000 Hz	____ dB			____ dB
* The frequency 3000 Hz is required for adjudication in Federal compensation cases. Was masking (narrow-band) utilized for Pure-Tone Audiometry? Yes ____ No ____ LEVEL: ____ dB
SPEECH AUDIOMETRY			RIGHT			LEFT
Speech Reception Threshold (SRT)			_____ dB			_____ dB
Auditory Discrimination Scores			_____ %			_____ %
Discrimination Test given at			_____ HL			_____ HL
Was masking (wide-band) utilized for speech audiometry? YES ____ NO ____ LEVEL: ____ dB Do the SRT and PTA (pure tone average) scores agree with 6 dB? YES ____ NO ____ If not, do they agree using the best two frequency "Fletcher" method? YES ____ NO ____ If not, please explain if you believe the discrepancy is of an organic or functional basis and include as much detail as you can? If there is a marked audiometric discrepancy between each ear, were there particular conditions of exposure or protection that justify this difference? Explain any such difference as fully as possible.