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Outline for Otologic Evaluation

U.S. Department of Labor
Office of Workers’ Compensation Programs
Division of Federal Employees' Compensation
OMB No. 1240-0046
Expiration Date: 8-31-2026

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 predicated on the basis of presbycusis?

(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, systemic diseases,
(such as diabetes) local infections, ototoxic drug usage, surgery, etc. as they relate to this individual's hearing loss
sensorineural or conductive.

If you have a disability and are in need of communication assistance (such as alternate formats or sign language
interpretation), accommodations and/or modifications, please contact OWCP.

CA-1332 (Rev. 03-18)

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OMB No: 1240-0046
Expiration Date: 8-31-2026

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.

Is there indication of tinnitus? If yes, please address any limitations in Activities of Daily Living (ADLs) resulting from the
tinnitus, including sleep, reading (and other tasks requiring concentration), enjoyment of quiet recreation and emotionalwell-being.

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

CA-1332 PAGE 2 (Rev. 03-18)

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OMB No: 1240-0046
Expiration Date: 8-31-2026

to noise exposure encountered in this claimant's Federal civilian employment.
If tinnitus is diagnosed, complete the following:
The tinnitus 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(s):

Recommendations:

Signature of Physician/Date

______________________________________________

CA-1332 PAGE 3 (Rev. 03-18)

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OMB No: 1240-0046
Expiration Date: 8-31-2026

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) __________________________________________________________
(Need to check below if still current)
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.

CA-1332 PAGE 4 (Rev. 03-18)

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OMB No: 1240-0046
Expiration Date: 8-31-2026

V. AUDIOMETRIC TEST RESULTS:
TO ELIMINATE THE POSSIBILITY OF TEMPORARY THRESHOLD SHIFT, THE PATIENT SHOULD NOT BE TESTED
UNLESS FREE OF SIGNIFICANT 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 ( )
Right Ear

No ( )

Left - Yes ( )
Left Ear

No ( )

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
Speech Reception Threshold (SRT)

RIGHT
_____ dB

LEFT
_____ dB

Auditory Discrimination Scores

_____ %

_____ %

Discrimination Test given at

_____ HL

_____ HL

Was masking (wide-band) utilized for speech audiometry? YES ____ NO ____
Do the SRT and PTA (pure tone average) scores agree with 6 dB?

LEVEL:

____ dB

YES ____ NO ____

If not, do they agree using the best two frequency "Fletcher" method? YES ____ NO ____

CA-1332 PAGE 5 (Rev. 03-18)

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OMB No: 1240-0046
Expiration Date: 8-31-2026

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.

CA-1332 PAGE 6 (Rev. 03-18)

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OMB No: 1240-0046
Expiration Date: 8-31-2026

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of
information unless it displays a currently valid OMB control number. 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. The obligation to respond to this
collection is required to obtain or retain a benefit under 5 U.S.C. 8101, et seq. Send comments regarding the
burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200
Constitution Avenue, NW, Washington, DC 20210, and reference the OMB Control Number 1240-0046. Note:
Please do not return the requested information to the address shown just above. Rather, send it to the address
shown on the letterhead.
Privacy Act Statement
The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation Act, as
amended and extended (5 U.S.C. 8101, et seq.), authorizes collection of this information. The information will
be used in conjunction with the Form CA-1331 to refer a claimant for complete audiologic and otologic
examination when a claim for hearing loss has been filed. Completion of this form is voluntary, however,
failure to provide the information may result in the delay of processing of the claim or payment or benefits, or
may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information
may be to: third parties in litigation; employing agencies, various individuals and organizations providing related
medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions;
various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as
appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit
bureaus.

CA-1332 PAGE 7 (Rev. 03-18)