Hearing Screen

Date:

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Testing & Results

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First Name:
Last Name:
Phone:
Birthdate:
Social Security#:
Current Employer:
Job Title:
Reason for Test
Baseline
Annual
Restest
Termination
Has it been more than 14 hours since your last noise exposure?
Do you Have:
Ringing in your ears
Problems with dizziness/unsteadiness
Any ear or hearing problems now
Noisy hobbies
Have you ever had:
Medical treatment for an ear problem
Sudden hearing loss
A noisy job with another company
Have you ever:
Used firearms
Served in the Armed Forces
Types of hearing protection used in the past:
Comments:
Ear Inspection (Check if True)
L                R
Eardrum Visible
Perforation
Drainage
Excess ear wax
Audiometer
Make:
Model:
Serial #:
Calib. Date:
Test Date:
Time:
Technician Cert. #
Left Ear
500
1000
2000
3000
4000
6000
8000
Right Ear
500
1000
2000
3000
4000
6000
8000
Contact
Find us

Carnegie Office:              Upper Burrell Office:

101 Ewing Road               4120 7th Street Road

Carnegie, PA 15106         Upper Burrell, PA 15068

 

info@momsllc.com

 

Tel:  

Karen Haws Clark:  724-575-9078,

         Justin S. Haws: 724-994-6442,

      

Fax: 724-594-0156

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Respirator Evaluation Questionnaire
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CERT# WBE183329