HEARING LOSS CLAIM ASSESSMENT FORM

Transcription

1 HEARING LOSS CLAIM ASSESSMENT FORM Name: Address: Post Code: Telephone: Date of Birth: Fire and Rescue Service: General Information: Making a claim against your employer for loss of hearing is a complex issue therefore this Claim Assessment form requires as much detail as you can provide ensure that a full assessment can be made. Hearing can be affected by many facrs which may not all be work related, therefore, lifestyle, hobbies, family hisry relating hearing loss and previous occupations have be taken in account. The following notes are a brief attempt assist you with understanding this wide ranging issue. Reduction in Hearing Ability During Employment Hearing capability decreases with age. Individuals may therefore meet employment standards when young, but fall below them after a number of years in employment. This decrease is unpredictable between individuals, and the noise exposure of firefighters is both variable and unpredictable. Although Employers should do their best ensure firefighters are protected from noise, the emergency nature of the task will at times expose individuals events such as explosions that could not have been foreseen and cannot be protected against. Investigating Hearing Loss Consideration of ise-induced Hearing Loss (NIHL) centres on a threshold notch at khz with a positive hisry of excessive noise exposure. However, this is not a prescriptive definition. If the criteria below are met, the hearing loss should merit specialist referral. of 0

2 Criteria for ise Induced Hearing Loss It is always sensorineural, affecting the hair cells in the inner ear. It is almost always bilateral and is usually symmetrical. The earliest damage the inner ear occurs at khz and is seen as a characteristic notch on the audiogram. Over time, this may deepen and widen as khz and khz become affected. High-frequency losses may reach 7 db and are always greater than low frequency losses (00 Hz, khz and khz) which may reach 0 db. It rarely produces a profound hearing loss. Once the exposure noise is discontinued, there is no significant further progression of the hearing loss. Previous NIHL does not make the ear more sensitive future noise exposure. Given stable exposure conditions, high-frequency losses usually reach their maximum level in about 0 years. Further loss is minimal and slow. Diagnosis is based on consistently raised audiry thresholds of the characteristic pattern, in association with a positive hisry for noise exposure. Tympanometric impedance testing should be performed by competent occupational health staff, in response an unexpected low-frequency hearing loss. If the hisry suggests an upper respirary tract infection and the tympanometry supports this, re-testing should be conducted once the sympms have resolved. Tinnitus Tinnitus is a sound which is audible the individual but has no external origin; this may be termed subjective tinnitus. Tinnitus is, in the majority of cases, a transient non-intrusive perception. 8% of the population experience tinnitus causing moderate severe annoyance but only 0.% experience tinnitus which is of such severity as effect their ability lead a normal life. The vast majority of people who experience tinnitus do not complain about it. However, any persistent tinnitus associated with noise exposure may require a firefighter be protected from further exposure, minimise the possibility of the sensation becoming worse. A number of reports have confirmed that the intrusiveness is correlated with psychological facrs. Severe intrusive tinnitus warrants detailed ological investigation. Before any decisions are made on redeployment or retirement, an opinion should be sought from a psychologist with particular expertise in this field. For further information go Please complete the following Questions and return this document : Fire Officers Association London Road Moren-in Marsh Gloucestershire GL 0RH Or by foa@fireofficers.org.uk of 0

3 . Please give details of all employers (starting with the first) and indicate if you believe they exposed you excessive noise this should include, the best of your recollection, names of employers, addresses if possible and periods of employment. Please include service in the armed forces. Name of Employer Position Held/Work Undertaken Dates of Employment Were you exposed excessive noise? of 0

4 . Please give details of any secondary employment including self-employment (starting with the first) and indicate if you believe your were exposed excessive noise this should include, the best of your recollection, nature of employment, addresses if you were employed by a third party and periods of employment. Name of Employer (put self where self employed) Position Held/Work Undertaken Dates of Employment Were you exposed excessive noise? of 0

5 . What was the source of the excessive noise? In the case of ols/machinery/process* please provide the name of the ol/machine and what it was used for. Please indicate which employer relates which ol/machinery/process/weaponary. Name of Employer Type of ol used or process* undertaken How many hours a day/week were you exposed excessive noise *Process includes any work activity. of 0

6 . Were you ever given any hearing protection and/or health and safety training regarding noise exposure? Name of Employer Hearing protection given. If,please give details Health & Safety training given. If, please give details i.e. were warning signs placed in your place of work Date this protection became available Was it compulsory wear protection Further comment regarding this question: of 0

7 . Have you ever been diagnosed as suffering from noise induced hearing loss/sought any medical advice regarding your hearing? Name of Employer Diagnosed as suffering from noise induced hearing loss. Did you seek medical advice from your GP/Hospital. (Please provide details of GP/Consultant who attended you) Date of Diagnosis, if applicable Date of treatment, if applicable 7 of 0

8 . Do you know of any work colleagues who have suffered similar sympms? Name of Colleague Address Telephone Number Was a colleague ever diagnosed with hearing loss? Has a colleague made a claim against their Employer. 8 of 0

9 7. In your estimation, at what levels were the noise levels at your place of work. E.g. Did you have shout be heard by your work colleagues? Name of Employer Level of ise: Did you have shout? (If please give details) 9 of 0

10 8. Have you had any previous problems with your hearing? Please give full details (Please include any birth disabilities, and childhood illnesses) 9. Do you undertake, or have you taken part in, any type of sound intensive hobbies or pastimes? (I.e. mor sport activities of any kind, use of firearms etc) Please give full details 0. If there is any further information you consider we require in order fairly assess your claim, please provide details. Following your completion of this questionnaire the Association may ask its solicirs forward you a number of forms of authority, which they will require in order access the full extent of any relevant records. We would be obliged if you would complete and sign the consent forms for access any records from your GP where you received treatment, any hospital where you received treatment, any counselling services where you received treatment, your occupational health notes and your personnel folder. FOR OFFICE USE ONLY: Date Membership Commenced: Membership Grade: Membership Number: Date Form Received: Receipt of form acknowledged: Form forwarded for opinion/review: Passed : 0 of 0