Worker's Report Occupational Noise Induced Hearing Loss

1 Toronto Ottawa London Windsor Kitchener Kingston North Bay Thunder Bay Timmins Hamilton Sudbury Guelph Sault 200 Front Street West 200, rue Front Ouest Worker's Report Toronto ON M5V 3J1 Toronto ON M5V 3J1 Occupational TorontoNoise Toll-Free: 1-800-387-0080 Sans frais : 1-800-387-0080 Induced Hearing loss help/tips Claim No. Desk Allocation No. Help/Tips 200 Front Street West 200, rue Front Ouest help/tips home Injury Toronto ON M5V 3J1 Toronto ON M5V 3J1 Home Help/Tips Appeals 1-800-387-0773 1-800-387-0773. Date of Injury (dd/mmm/yyyy). print home Print Home Employer 200 Front Street West, 7th Floor 200, rue Front Ouest, 7 e tage Reset reset print Toronto ON M5V 3J1 Toronto ON M5V 3J1 To enquire, contact Print Finance 1-800-387-0750 1-800-387-0750. ( ). reset this Reset This reset page Reset For toll free number, check local directory Page 99 Metcalfe Street, Suite 700 99, rue Metcalfe, bureau 700.

2 Home address and postal code if different from above. Ottawa ON K1P 1E8 Ottawa ON K1P 1E8 Ottawa Toll-Free: 1-800-267-9601 Sans frais : 1-800-267-9601. reset this Reset This page Page Date of Birth (dd/mmm/yyyy) Social Insurance No. Miner's Certificate No. or Payroll No. Language Spoken if Not English 148 Fullarton Street 148, rue Fullarton London ON N6A 5P3 London ON N6A 5P3 London Toll-Free: 1-800-265-4752 Sans frais : 1-800-265-4752. Was the change in your Hearing gradual? Yes No Does your Hearing change from day to day? Yes No Date Received (dd/mmm/yyyy). Are you bothered by ringing 2485 Ouellette Avenue in your ears? Yes No 2485, avenue Do you have a hearingOuellette aid? Yes No Windsor ON N8X 1L5 Windsor ON N8X 1L5 Windsor Exam Date (dd/mmm/yyyy) Toll-Free: 1-800-265-7380 Sans Name and address of Ear, Nose and frais Throat :Specialist 1-800-265-7380. Canada Trust Centre Canada Trust Centre 55 King Have you had your Hearing tested?

3 StreetName West, and3rd of Audiologist 55, rue King Ouest, 3 e tage Floor address Kitchener Kitchener ON N2G 4W1 Kitchener ON N2G 4W1. Toll-Free: 1-800-265-2570 Sans frais : 1-800-265-2570. Yes No Do you or have you ever used noisy What Type? Frequency 234 Concession Street, 234, rue Concession, machinery, equipment or firearms outside of work? Suite 304 Yes No bureau 304 Kingston Kingston ON K7K 6W6 Kingston ON K7K 6W6. Of all the noisy jobs you may Toll-Free: 1-800-267-9461. have had, which do you feel Name and address Sans frais : of1-800-267-9461. your current employer (if applicable). is the most responsible for your Hearing loss ? 301 St. Paul Street, 8th Floor Do you work in a posted Noise level area? 301, rue St. Paul, 8 e tage If yes, what is the decibel level posted? St. Catharines ON L2R 7R4 St. Catharines ON L2R 7R4 St. Catharines Yes No Toll-Free: 1-800-263-2484 Sans frais : 1-800-263-2484.

4 Provide names and addresses of two co-workers who can confirm your Noise exposure at this place of employment. Name Address 128 McIntyre Street West 128, rue McIntyre Ouest Name North Bay ON P1B 2Y6 Address North Bay ON P1B 2Y6 North Bay Toll-Free: 1-800-461-9521 Sans frais : 1-800-461-9521. Do you still work in hazardous Noise conditions? If retired, (dd/mmm/yyyy) Are you unemployed? provide retirement Yes No Yes No date. 0032A (02/06). For PDF's with address buttons HL6..next page Start with your first employer first and continue to your Claim Please provide your entire work history. most recent employer. Please be as detailed as possible. Number Employment Dates Exposure Ear Plant Is Employer Employer's Name, Equipment (dd/mmm/yyyy) Occupation Protection? Area Still In Address & Province Used Hours/Day From To Business? Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No No Please provide the name of your union (if member) Local Contact Person Telephone No.

5 Sometimes an employer may request the WSIB to disclose a social insurance number in order to locate records to confirm past employment. Would you consent to allowing the WSIB to disclose your social insurance number for the purpose of confirming your past employment. I consent to allowing WSIB to disclose my social insurance number for the purpose of confirming my past employment. Signature Date (dd/mmm/yyyy). Please print form & sign before returning to the WSIB. I declare all the above information is true and correct. By signing below, I am claiming benefits under the Workplace Safety and Insurance Act, 1997, for a work-related disease ( Hearing loss ). I authorize any health professional who treats me to give me, my employer and the Workplace Safety and Insurance Board, information about my functional abilities with respect to Hearing on the WSIB Functional Abilities Form for Timely Return to Work.

6 Signature Date (dd/mmm/yyyy) Telephone No. Please print form & sign before returning to the WSIB. ( ). Personal information about you will be collected throughout your claim under the authority of the Freedom of Information and Protection of Privacy Act and will be used to administer the Workplace Safety and Insurance Act, 1997, your claim and programs of the Board. Medical and non-medical information is collected from health care providers, vocational agencies, labour market service providers, employers, witnesses, and others as required. Your Social Insurance Number is used to register claims, identify workers and to issue income tax receipts and is collected under the authority of the Income Tax Act. Information may only be disclosed to the employer, external medical, vocational, and safety agencies, external payment and service providers, researchers, and others as authorized by the Workplace Safety and Insurance Act and the Freedom of Information and Protection of Privacy Act.

7 Your name and telephone number help/tips may be disclosed to third party researchers conducting satisfaction surveys and focus groups. Questions should be directed to the decision maker responsible Help/Tips for your file or toll free at 1-800-387-5540. home You must give a copy of this form to the employer who you worked for most recently in Home 0032A2 work associated with this disease print Print