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Form 252007A0

HEARING IMPAIRMENT
CALCULATION WORKSHEET
Date
Name
Claim numberDate of audiogram
Hours since last exposure to noise
(must be more than 14)
A.N.S.I. 1969
Monaural Hearing Loss Formula:
STOP HERE IF EITHER OF THE MONAURAL HEARING LOSS %'s ARE ZERO!!!
********************************************************************************************************
Combined Hearing Loss Formula:
([ % better ear x 5 ] + [% worse ear]) ÷ 6 = % of loss
% better ear
Plus % worse ear
Sub-Total divided by 6
x 5 =
+
Sub-Total
% Binaural
Hearing Loss
F252-007-000 hearing impairment calculation worksheet 9-00
Department of Labor & Industries
Office of The Medical Director
PO Box 44321
Olympia WA 98504-4321
Hz
500
1000
2000
3000
T otal
÷ 4 =
- 25 =
x 1.5 =
([([500 Hz + 1000 Hz + 2000 Hz + 3000 Hz] ÷ 4) - 25] x 1.5) = % of loss
Hz
500
1000
2000
3000
÷ 4 =
- 25 =
x 1.5 =
÷ 6 =
STOP here if total is 100 or less
STOP here if total is 100 or less
LEFT EAR (X)
A vg threshold for
4 frequencies
Less threshold
fence of 25 dB
Multiplied by 1.5
equals the % of
monaural loss
Add rating for tinnitus
of 0 through 5%
T otal percent monaural
hearing loss
A vg threshold for
4 frequencies
Less threshold
fence of 25 dB
Multiplied by 1.5
equals the % of
monaural loss
Add rating for tinnitus
of 0 through 5%
T otal percent monaural
hearing loss
RIGHT EAR (0)
dB level
dB level
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