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Office of Management & Finance

Bureau of Internal Business Services

BIBS is the provider of central services for the City of Portland

Employee Form for Clinic Testing

City Risk LogoLoss Prevention

Risk Management, Portland, OR


Note: Bills to be sent to WA Audiology


Employee name


Hearing Test Date 


This individual has been instructed to obtain a hearing test as part of his/her required participation in a hearing conservation program provided by his/her employer. This hearing conservation program is in accordance with Oregon Administrative Rules (OAR) Chapter 437. Please adhere strictly with the outline below which summarizes what is required of your clinic with regards to this hearing test.


  • Pure tone, air conduction audiometric testing only, using supra-aural earphones. Please obtain thresholds bilaterally at the following frequencies: 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hz. 
  • Please use the attached form for recording threshold and medical history information. Please note that the employee must sign the statement at the bottom which authorizes his/her release of information to employer designated health care providers for the purposes of the hearing conservation program. 
  • Results are to be sent or faxed to Washington Audiology Services along with this instruction sheet within 48 hours of the date of testing. This is critical because retesting, if applicable, is only permitted within a specified period of time from the original test date.
  • Hearing tests must meet OR-OSHA standards for hearing conservation programs. This means that certain required standards apply to hearing testers, audiometers, sound booths, etc. You already have or will be asked by Washington Audiology Services, Inc. to complete a survey to ensure that you meet these requirements and you may be asked to provide them with records to document this compliance. Your support is requested in this very critical process.


The following requirements must be met for the hearing test to be recognized as valid by OR-OSHA and other governing agencies. Please initial each requirement that was successfully met in the completion of today’s test for the above employee. Then provide your signature at the bottom.

_____Administered by a licensed or certified audiologist, otolaryngologist or other qualified physician, or by a CAOHC certified technician responsible to one of the above. Please provide certification number:

_____Performed in a sound-attenuated room that does not exceed OR-OSHA’s current permissible levels for background ambient noise (40@ 500Hz; 40@ 1000Hz; 47@ 2000Hz, 57@4000Hz;62@8000Hz)

_____Equipment calibrated to current ANSI standards; Calibration date:

_____Thresholds were obtained and recorded for each ear for the following frequencies: 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hz 

_____A biological check of the audiometer’s reliability was performed and documented on the date of test prior to the testing.


Print Name

Thank you for your cooperation in these matters. Please contact Washington Audiology Services, Inc. with any questions you may have. Hearing Conservation Program, City of Portland


Washington Audiology Services, Inc.

6987 Perimeter Road So, Ste 100 Seattle, WA 98108

Phone: 206.764.3330; 800.442.1573 Fax: 206 764-4760