This form is for workers, to request a copy of your industrial audiometric hearing test results for your own records. Note that you do not need to request these results to include with your hearing loss claim. The claims department already has access to the results to assist with claim adjudication.

You can print this form and complete it by hand, then scan or photograph it and email it to IndustrialAudiometrics@worksafebc.com.

Alternatively, the form can be completed digitally using Adobe Acrobat. If you don’t already have Acrobat on your computer, you can download Adobe Acrobat Reader, a free app, from get.adobe.com/reader.

Please note the form’s functionality will not work properly if the form is opened in an internet browser such as Microsoft Edge or Google Chrome.

To complete and submit the form digitally:

1. Click the Download PDF button. The form will be copied to the Downloads folder on your computer hard drive.
2. Open the form in Acrobat by going to your Downloads folder and right-clicking on the PDF file. Select Open with > Adobe Acrobat Reader.
3. Type your information in the form, save your form, and then click the Submit button at the end of the form.
4. An email to IndustrialAudiometrics@worksafebc.com will pop up. Ensure your completed form is attached, then click Send.