Audiogram Log Sheet
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1Boilermaker National Audiometric Testing Program
INITIAL
RETEST
AUDIOGRAM
DATE
YR.
MO. DAY
NAME
SEX
LAST NAME
FIRST NAME
MI
D.O.B.
IBB Registration No.
YR.
MO. DAY
ADDRESS
POSTAL CODE
Rigger/Fitter
Apprentice
PRIMARY OCCUPATION TYPE
HOME LOCAL
Welder
Shop
OTHER
NO
YES
NO
YES
1. Do you have a cold or flu now?
8. Exposure to a loud blast or noise?
2. Any change in hearing in the last year?
NO
YES
9. Any change In ability to hear conversation or emergency signals?
NO
YES
If yes , explain
3. Have you had:
If yes, explain
Head injury
NO
YES
Earache
NO
YES
Ringing in ear
NO
YES
Ear infection
NO
YES
10. Are you noise exposed on the job?
NO
YES
Sinus infection
NO
YES
Dizziness
NO
YES
11. Were you noise exposed prior to test?
NO
YES
4. Have you seen a Doctor for hearing problems?
NO
YES
Was hearing protection worn?
NO
YES
Dr.
Date
12. Type of hearing protection?
PLUGS
MUFFS
5. Do you wear a Hearing Aid(s)?
NO
YES
(check all that apply)
NONE
CUSTOM
6. Are you exposed to recreational noise?
(check all that apply)
loud music
snowmobiles
motorcycles
Technicians Comments:
home workshop
farming
other
EXPLAIN (HOW OFTEN ETC.)
7. Do you hunt or use firearms?
NO
YES
Which shoulder do you shoot from?
Right
Left
Both
Left
X
Test Accuracy
GOOD
FAIR
POOR
Right
O
Ear Canal R:
CLEAR & UNOBSTRUCTED
BLOCKED
Ear Canal L:
CLEAR & UNOBSTRUCTED
BLOCKED
Technician
Certification
Make & Model
Ser. No.
Date Calibrated
Clinic ID
Frequency (Hz)
INTERPRETATION
500
1000
2000
3000
4000
6000
8000
-10
-10
500
1000
2000
3000
4000
6000
8000
0
0
L
10
10
20
20
R
30
30
40
40
INITIAL/BASELINE TEST
PERIODIC/ANNUAL TEST
50
50
Abnormal
Abnormal Change
60
60
Early Warning
Early Warning Change
70
70
Normal
Normal Change
80
80
Audiologist Signature:
90
90
100
100
Member’s Consent: I consent to the audiometric testing and understand that all information
I have received a hearing test and the results have been explained.
will be held in strict confidence by the IBB and/or the Boilermakers' National Health and
Welfare Plan (Canada) (the "Plan"), in accordance with the guidelines set forth by the Alberta
Personal Information Protection Act or applicable privacy statutes. I authorize IBB and the
Plan to release information pertaining to my audiometric test only as required by the
applicable workplace health and safety or worker compensation statues. The IBB and the
MEMBER SIGNATURE
Plan will comply with all applicable privacy and employment-related provincial statutes.
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