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Work Incident Report Form
Respect to the provision of hearing
services and devices to workers.
This form should be completed by the audiologist or audiometrist approved by WorkSafe to provide hearing services to injured workers with a work-related hearing
loss and who has performed the assessment on the worker. The completed form must be sent to the WorkSafe Agent or self-insurer following assessment. All
sections should be completed. Please provide reasons if you are unable to complete a section of the form as...
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