Employee Name

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* 1. Employee Name

Employee ID Number

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* 2. Employee ID Number

Supervisor Name

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* 3. Supervisor Name

Date of Birth

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* 4. Date of Birth

Employer Name and Location

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* 5. Employer Name and Location

Job Title

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* 6. Job Title

Do you have any allergies. If so - Please state what they are

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* 29. Do you have any allergies. If so - Please state what they are

Were you exposed to loud noise prior to this hearing test? If so, how long? Did you wear protection?

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* 31. Were you exposed to loud noise prior to this hearing test? If so, how long? Did you wear protection?

Have you served in the military? If so, how many years?

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* 33. Have you served in the military? If so, how many years?

Do you have noisy hobbies? Please list...

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* 34. Do you have noisy hobbies? Please list...

Do you shoot firearms/guns? If so, for how long? Which hand do you use to pull the trigger?

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* 36. Do you shoot firearms/guns? If so, for how long? Which hand do you use to pull the trigger?

Do you take prescription medication? Please list...

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* 38. Do you take prescription medication? Please list...

Do you take aspirin? How much and how often?

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* 39. Do you take aspirin? How much and how often?

Do you use chainsaws? Please list % Personal and Work use

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* 40. Do you use chainsaws? Please list % Personal and Work use

Do you use power lawn equipment? Please list % of Personal and Work use

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* 41. Do you use power lawn equipment? Please list % of Personal and Work use

Do you use farm equipment? Please list % of Personal and Work use

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* 42. Do you use farm equipment? Please list % of Personal and Work use

Do you use power tools? Please list % of Personal and Work use.

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* 43. Do you use power tools? Please list % of Personal and Work use.

Do you ride motorcycles? Do you wear hearing protection? 

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* 44. Do you ride motorcycles? Do you wear hearing protection? 

Do you ride power boats? Do you wear hearing protection?

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* 45. Do you ride power boats? Do you wear hearing protection?

Do you ride snowmobiles? Do you wear hearing protection?

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* 46. Do you ride snowmobiles? Do you wear hearing protection?

Do you ride ATV's? Do you wear hearing protection?

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* 47. Do you ride ATV's? Do you wear hearing protection?

Do you play in a band? Do you wear hearing protection?

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* 48. Do you play in a band? Do you wear hearing protection?

Are you a spectator to other loud activities (Concerts, Auto racing, etc)? Please list

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* 49. Are you a spectator to other loud activities (Concerts, Auto racing, etc)? Please list

Please list any other activities that could be considered loud that you are involved in. Please document how many years you have been involved...

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* 50. Please list any other activities that could be considered loud that you are involved in. Please document how many years you have been involved...

Employee Signature - By typing your name you attest that the information provided on this questionnaire is true and accurate to the best of your knowledge

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* 51. Employee Signature - By typing your name you attest that the information provided on this questionnaire is true and accurate to the best of your knowledge

Date

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* 52. Date

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