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Fillable Printable Form 252007A0

Fillable Printable Form 252007A0

Form 252007A0

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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