Free F2527hrg.eps - Washington

Department of Labor & Industries Office of The Medical Director PO Box 44321 Olympia WA 98504-4321 Date Name Date of audiogram

HEARING IMPAIRMENT CALCULATION WORKSHEET
Claim number Hours since last exposure to noise (must be more than 14)

A.N.S.I. 1969 Monaural Hearing Loss Formula: ([([500 Hz + 1000 Hz + 2000 Hz + 3000 Hz] ÷ 4) - 25] x 1.5) = % of loss LEFT EAR (X) dB level RIGHT EAR (0) dB level

Hz 500 1000 2000 3000 Total

Hz 500 1000 2000 3000

STOP here if total is 100 or less

STOP here if total is 100 or less

Avg threshold for 4 frequencies Less threshold fence of 25 dB

÷ 4=

Avg threshold for ÷ 4 = 4 frequencies Less threshold fence of 25 dB
- 25 =

- 25 =

Multiplied by 1.5 equals the % of x 1.5 = monaural loss Add rating for tinnitus of 0 through 5% Total percent monaural hearing loss

Multiplied by 1.5 equals the % of x 1.5 = monaural loss Add rating for tinnitus of 0 through 5% Total percent monaural hearing loss

STOP HERE IF EITHER OF THE MONAURAL HEARING LOSS %'s ARE ZERO!!!
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Combined Hearing Loss Formula: ([ % better ear x 5 ] + [% worse ear]) ÷ 6 = % of loss
% better ear Plus % worse ear x 5 = + Sub-Total Sub-Total divided by 6 ÷6= % Binaural Hearing Loss

F252-007-000 hearing impairment calculation worksheet 9-00