Free OD-5 Form - Nevada

Firemen And Police Officer's Hearing Examination Form
Name (Last, First, Middle) Sex Date of Examination

Address

Age

Date of Birth

Personal Physician's Name

Occupation

Audiometric Results
Frequency in Hertz (Hz), Right Ear
500 1000 2000 3000 4000 6000 8000

Frequency in Hertz (Hz), Left Ear
500 1000 2000 3000 4000 6000 8000

Average of 2K, 3K, and 4K Results: Otoscopic Examination Right Left Normal Appearance Excessive Wax or Debris Abnormal Appearance

Average of 2K, 3K, and 4K Results: Remarks

RECOMMENDATIONS Medical Referral Retest Recommended Complete Audiogram
Audiometer Tester's Name Title Serial Number Tester's Signature Calbration Date Test Date and Time

Please sign one copy of this form and submit it to your employer or organization.
Employee's Signature Date

Form OD-5 (rev. 7/99)