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On Site Courses
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Health and Wellness Division
CEU Certification
Schedule
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Contact
780-417-3777
Map
About Us
Services Offered
On Site Courses
Online Courses
Health and Wellness Division
CEU Certification
Schedule
Training Locations
Contact
780-417-3777
Map
Audiometric Data Sheet
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Audiometric Data Sheet
AT Safety Training - Audiometric Data Sheet
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Company Name
Name
*
First
Middle
Last
Gender
*
- Please select -
Male
Female
Phone
*
Email Address
*
Union Member
*
- Please select -
Yes
No
Name of Union
*
Current Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
General Questions
General Questions(Pl check for YES and leave blank for NO)
Do you Wear Hearing Protection regularly?
Have You Been Exposed to loud Noise in the past 14 hours without Hearing Protection?
Do you presently have a head cold or severe sinus?
Have you visited a physician for your hearing in the last year?
Are you Aware of any hearing loss?
Do you wear Hearing protection during/off job or noisy activities?
Do you have dizziness or balance problems?
Do you have ringing or roaring in your ears?
have you had a exposure to fire arms?
Do you take prescription drugs?
Have you been in Military Service?
Have you ever had your hearing tested?
Have you ever worked in noise?
Do you have excessive ear wax?
Do you have earaches or ear drainage?
Have you had a severe head injury?
Patients Signature
Clear Signature
For Office use Only
Otoscopic Screening(Right)
N
B
P
U
Otoscopic Screening(Left)
N
B
P
U
Right Ear Test Results
500
1000
2000
3000
4000
6000
8000
Left Ear Test Results
500
1000
2000
3000
4000
6000
8000
Test Date
Sign on behalf of AT Safety
Clear Signature
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