CA-1332.pdf

OWCP HEARING LOSS MEDICAL REQUIREMENTS

Each employe€ slDuld bc seen for rudiologic rnd otologicrl cxrminrtion. Tt. iudidodcrl te$ting should pr€{€d€ the visit to the otolo8ist; fte otologist should havc thc &diological firtings d the tim€ of the etrmioalion; and, to the ext4nt possibte, $ese two consulhtions aho$ld occur or the samc dsy. lt is rlso rcquircd that th€ ludiologic.l and orological examinations b€ perfofln€d by differenr individuals.

Any lests rdministercd as pdn of an iudiological brttery must bc q)nd{stcd by r psrsor poss€ssiog certifications in audiology frorn 6e Americrtl Sprcah-Lln8uqc-Hcaring Association (ASHA] or Sr$c Iiccnluc as an ludiologist. Th€ mcdic.l craminlrion must be perforn d by en orolaryqologirt ccrrifrcd (or cligibl€ for csrificarion) by rhc Aneric|n Ac.dcmy of Oiol.ryngology- All tcsts comprisinS rhE brtlcry rdoioist red in thc audiologic evdu{ion must bc pe.formad in enviroruncnt nestiDg the sp€cificttions of ANSI S3.I (197). Ficilities which are accr.dil€d by the Prof€s6idEl S€rvicc Boad of th€ ASHA me€{ lhis r€quircment. Tcsting cqlipnrnt must bc calibrated in accordarr€ with th€ protosol conoi[ed in the accreditation msnuel ofASHA'J Professional Serlice Board (ANS[ 53.6- 1969).

Audiometic rcsts rnusr includcthc followrrg:

l. Purc-tone ar conduction thresholds lhould tle obtained tbr each e3. al500, 1000, 2@0. 3000. 4000, 6m0, and 6000 Hz. Bone conducdon tfuesbolda 6hould bc ob(rin.d for $c spccrfied fuqucncics from 5m to 40m Hz, irrlusive- Approp.iate nasting should b€ employed as rEc€srary .rd rhe urc of masking should be dcnocd on tha audiogreln. I hc syinhols uqd iD rccording thrGhlds sbould be in accordanc€ with thc most rcccnt ASIIA recommcldstions,

2. Impedtncc iudiolrFtry should bc dorl. or botlt c{rs a9 s Elcans of deGrlliDiDt the reliability of ai.-bond corduction thrcshold rcktionsbips rnd for sny conuibu on ir might o$fi*irc mekg e differc irl dirgnosis by thr physicien,

3. Spccch n cption thrcaholds fo( each car $hould be estrbli6hed lsing tlst proa4dures md spordaic *ords which codfortn ro guidclines (ASHA Commitc. on Audiolrlnic Evrluation, 1979).

Stlrdardiz€d rerorded matcrills should be us€d rarller |han live rcic€s.

4. Monrull d(crihiMiion scorcs should be obr.ir€d: masking should bc used wh€n necessary.

St.dardiz.d rccotdcd word hcrs should s€rla rs ihc stimuli ind the drsc.imimtbn seres fdi the iull Iist should be reported for €ach €ar.

Repods must includc, as apprcpriab:

l. Date ud ho$r of examinarioni

2. Drtc rrd hout of employr€'s hst exposurc to loud noisc. (If Uc efiploycc wrs erposcd to noise withio the last 16 hours. do not rrocccd \rirh t.stin!:

Hisiory of injuryi The physician's rllionaliz.d medical opinion regarding fte rchdo|l ofrhc hefting losr lo clnploymc -rdlttcd noisc cxF,surc!

Thc physici.n's rcomlned.ti.'r for tearn nr;

A cerlificadon musr a.company €ach Ndiological batery indic ng that insronent calibration and the cnvironmcrt in whrch the tests were conducted met lhe ffcr€dibtion st.nd.tAs of th€ ProfksroMl Ssvices Boord for ASHA (ANSI 51.6 ( 1969) ind S3.I ( 1977 ), respcclivcly). Acopyofrhc c.libntio! sbndards arc auched for your conveoiencq and.

A sl|lemetu commenling on rhe relirbiliry of lhe lesls.

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Outline for Otologic Evaluation oMa No. 1215{103 Expires: oa-31.o5

NAMEj

FILE NUMBER:

I, HISTORY:

(A) Our adjudication and possible awards are based solely on the fact of causallty of all or a portion of the loss arising from exposure related to Federal Civllian employment. The only history of nolse exposure on which this case can be legltlmately adludicated ls that defined by the Statement of Accepted Facts. lfthere is any varlance in the history as given by the patient and that contained in the Statement of Accepted Facts, lt should be carefully considered and commented upon, but the oplnion you render must be based solely on the Statement of Accepted Facts.

IS THERE ANY SIGNIFICANT VARIATION FROM THE STATEMENT OF ACCEPTED FACTS?

(B) Please comment on thls patient's hearing at the beglnnlng of hls/her slgnlflcant noise exposure in Federal clvlllan employment, if audiometric data is avallable.

(C) Compare, if possible, the present audiometric findlngs to those at the beginning of exposure.

Does thls individual show a sensorlneural loss that is in excess of what would be normallv Dre-dicated on the basis of oresbvcusus?

(D) Was the workplace exposure, as described in the material provlded, sufflclent as to Intenslty and duration to have caused the loss in ouestlon?

(E) Please provide all other relevant historlcal facts, (such as other nolse exposure) emotlonal disorders, sysmetlc dlseases, (such as diabetes) local Infections, ototoxlc drug usage, surgery, etc.

as they relate to this Individual's hearing loss sensorlneural or conductive.

Publlc Burden Slaaomonr

Th€ lnformation pfov ded wil be us€d lo delerm ne e igibi ry Io benellits and is requned ro obrain a b€.elit (5 usc 8lo1 el seq.) (PL 99-5oo) Plblrc reponing burdo. lor lhis colecton ol niormation ls estimai€d to vary from 15 io 45 minutBs per.esponse wnh a. aveGge of 30 m.utes per rospons€, including lim€ for.eviewing insrrLrctio.s, searching exisring data sou.ces, gathsring a.d hainraining lhe dara noeded and compeling and rsviewing the co lecton oI information S€nd conmenrs regarding the bu.ftn esri/nale or any othsr asped ot this colreclion of inlormalion, inc uding suggeslions for .educiag lhis burden, lo lhe Ollice ol Workers' Compension Programs, U.S. D€panmeni 9f !49'r l!9rj!49, r00 r9!!!' !911"e!!94.wlt!!t!191q Persons afe nol rsquired to respond lo lhis collecrion of inlormation unless it discplays a cLrre.tly valid OMB conrot numb€r.

OO NOT SEND THE COMPLETED FONM TO THIS OFFICE

U,S. DeDartment of Labor Emolovhent Standards Administration Oflice otworkers Compensation Programs D vision of Fede.al Employ€ss' Compensslion

II. ftIYSICAL EXAM

Plsaso mske this as oxtensivo as n€csssary in lins v{ith any tindings b€aring on this individual's befing lo$.

lf only a minimal noto ls roqulrsd, pleaso includ6 at l6ast the following:

Dosqlb€ the canals and drums.

Drum Morility:

Result of 86sic tork tesls:

ls th€ro indication ot any m€dicel co.ldition such as an acoustic neurofie or m6nisre'8 dis6aso? Plo€so sxolain.

othor:

t. oPtNtoN

DIAGNOSIS:

lt ssnsorinoural or mixed, complote tho following:

Tho sgmorinoural hgaring lc8 s€on iB, in pan or all, in my opinion

I oue lo noisa exposure tr gncounlored in

NOT DIJE

this clalmant's Federal civilian omployn€nt.

M€dical rationals suppo{ting the above position:

Rocommendations:

t

Signeture of Physician

NAME:

FILE NUMBER:

Audiologist's Name

IV, VERIFICATION OF AUDIOMETRIC TESTING

AUDIOGRAM IS ONLY ACCEPTABLE FOR USE IF AUDIOLOGIST IS AHSA CERTIFIED OR HAS A STATE

LICENSE - REFER FOR TESTING IF OFFICE AUDIOLOGIST DOES NOT MEET THIS CRITERIA,

ASHA Cert. l.D. State License l.D.

THE AUDIOMETER MUST MEET THE TEST ENVIRONMENT STANDARDS AS OUTLINED IN THE ATTACHED cA - 1087.

Audiometer:

Manufacturer Mod€l Serial No.

Type (msnual, automalic, microprocassor)

CALIBRATION (BN. NO. 82-18 reOUir€s annual calibration to ANSI 1969 Standards)

Date calibrated: Monlh Day Year

By Whom

Audiologist

Physician

Please note the lollowing poinls which are commonly miss€d and wilhout which adjudication cannot be compleled.

(1) Please include your complete audiograms with air conduction thresholds betw€en 500 and 8O0O Hz.

and bone conductaon thresholds between 500 and 4000 Hz. Ploase include impodance audiom€t.y.

(2) Be sure your calibration js up lo date according to onclosed CA-1087.

(3) Be sure the audiologisl is stale liconsed, or certilied in audiology by lhe American Speech Language Hearing Associalion.

(4) 8e sure all opinions are compleled and signed by the appropriate individuals.

The audiometric tesl results are valid and rep.esentalive of this employ€e's h€aring seositivity, fl ves n No lf you have reservations concerning the audiometric lesl findings, please state whal additional evaluaiions or tests you would suggest.

BOTH SIGNATURES ARE FEQUIRED. IF THE OPINIONS VARY, PLEASE ATTACH A SIGNED SHEET WITH

EXPLICATIVE RATIONALE,

Signature

Signature

V. AUDIOMETRIC TEST RESULTS:

TO ELIMINATE THE POSSIBILITY OF TEMPOMRY THRESHOLD SHIFT, IHE PATIENT SHOULD NOT

BE TESTED UNLESS FREE OF SIGNIFICANT NOISE EXPOSURE FOR AT LEAST 16 HOURS . OTHERWISE

RESCHEDULE. PATIENT FREE FROM NOISE EXPOSURE FOR - HOURS PRIOR TO TESTING.

Audiometric lesting completsd on at _ (dare) (hou.)

Pure-lon€ Audiometry (please also include your complete audiograms with air conduction thr€shold from 500 through 8000 Hz; bone conduclion from 500 through /O00 Hz; and the tympanogran, acoustic retlexos andlor other impedance testing as outlinsd in Instruction CA-1087.)

ls a significant air-bone gap prosenl?

Fight - Yes O No O Lefl - Yes O No o

Right Ear L€ft Ear

AIR BONE AIR BONE

5 0 0 _ A z _ d B _ d B _ d B

1 0 0 0 - H z d B - d B - d B

2 0 0 0 _ H z _ d B _ d B _ d B 3000 Hz o E - d B _ d B ' The frequency 3000 Hz is required lo. adjudication in F€deral compensalion cases.

Was masking (narrow-band) utilized for Pure-Tone Audiomelry?

Yes No LEVEL: - dB

SPEECH AUDIOMETRY RIGHT LEFT

Speech Rec€ption Threshold (SRT) - dB - dB

Audilory Discrimination Scores

Discrimination T€st givon al HL HL

Was masking (wide-band) utiliz€d tor sp€ech audiometry?

YES NO LEVEL: dB

Do the SRT and PTA (puro lone average) scores agree with 6 dB?

YES NO

YES __ NO

lf nol, do lhsy agree using lhe best two frequsncy "Flelcher" method?

l{ nol, please explain i f you beli€ve the discrepancy is of an organic or lunctional b6sis and include as much delai l as you can?

11 there is a matked audiomelrac discrepancy between each ear, were there particular conditions of exposur€ or proteciion that justify this difference? Explain any such difference as fully as possible.

7J.4 Cdibrlrion: Thc progrrn shllt establith snd follow polici.s and pmccdurcs fo( crlikdioo of rll a]tdi9ticEig clgprnent {Aich dccr rhc rcquirem€nh of rh€ AJncrican Nrri;nal Standards Spccific{ir)rN for Audioberic (ANSI 53.6.1969).

lg!+ T1" pi9.gj.r :ha ke€p an accurate record ol El audiomelac callbratio.ts perlomoo, I ne recofO 6hall include at lea3t:

Typc of cnlibradon-$iologic!1, clcctro..oustk. qc.

Dslc p€rfo.mcd.

All measulanrcnB obtrined

E{oipment calibrared (meb, iiodll, s€rial Numbe.).

Cllibndon cquipmett urad (n lc, dtodcl, s€rial Number).

48!a Diagnostic audiometec and/or audiomets.s u6€d in fired tooatjms shafi m€€t ANSI 53.6,19@ specificalions tor wtde-range audiometers and sha be catibraled according tJ ne iorlrcwtng schedule:

Daily: A Mcf biolodcrl check of the audiomrc.lo cnsurc p.ope, operaring ofd€r 3hdl bc mdc €ach dry thc audiotialq ii itr use, Monthly

(l) A d€biled biologicd chc.t of rhc audiornetrr whicb iftludcs a crrcful listenilg t 6t of

.arphoncs and bone vitrrato! shall bc pcrforrrcd to eosure rhAt thc rudiofcrcr di$plays no

(i) Cros. rrlt

(ii) Sigtrsl distortion

(iii) Abnorrul noise.

(2) An electorconatic cslibntion chr.k of non-solid-strrc audiomerers shall be nade once s month which includcs at lcasr rhc folkrwing measurcrFnts:

(i) Tbe lccMec) ot the $ound prcssurc lcvels for rll Frrc tixrcs in both e.rphobas.

(ii) Th€ lccur.cy of de 6ourd p.cseuc tevet for all maxking nois.s in borh@pholp,

(iii) Thc accuncy of$e soond prcssurc lcvcls frr sDe€ch sigrEls in all sound fi;I loudspcrlcfs.

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c. Qoartrrly: An clccrorcourtr calibrario! ch.ck of sglEljglE audiorrcrcrs shdl be ftrdc oruc every lhEe months which includcs !a le!$ thc mc,3urcrneotr spccified in Scction 7 3 a 2(2XI) throush (iv).

d. Annu.lly: An clcctrorcoulric calibrauon chs:k of a audiomelc{s shsll bc mrdc cvcry 12 n)nlhs which ircludcs rr lcall $c fdlowing nr€asurcmcalsl

The accuracy ofourpnt levels for ril pllle rone! in bone vibralo(s) The ac.uecy of |h. hcquerry calibrarion for purc roncs Hsl )nic diJitortion for ourc lorcr The accumcy ofri$y'decay tirnr for all pure tonca Signal-lo-noisc rrrio fordl outpuh AccuraEy of arcnuaor linc{rity Accuncy ol siSnal palamrreff udljzd in lpcciat dia8rostic tests, includiog 'mpedancc/admittaoca.

f.recdoh liom shock hazard

0 ) (z') (3) (4) (5) (6) (7)

(8)