Worker’s Report – Work Related Noise-Induced Hearing Loss – WSIB in Ontario

This form is used by workers in Ontario to report work-related noise-induced hearing loss to the Workplace Safety and Insurance Board (WSIB). The form ensures that all relevant details about the worker’s hearing loss and exposure to noise at work are documented comprehensively to facilitate the processing of the WSIB claim.

For alternative formats, contact WSIB at accessibility@wsib.on.ca. This document is also available in French.

To fill out this form, follow these instructions:

Section A: Worker Information

Personal Details

1. • Last Name, First Name: Enter your full legal name.
   • Address: Include your complete residential address (number, street, apartment/suite/unit).
   • City/Town, Province, Postal Code: Provide the relevant details for your location.
   • Telephone Number, Email Address: Enter your current contact details.
   • Date of Birth: Use the format (dd/mmm/yyyy).
   • Social Insurance Number: Provide your SIN for identification purposes.
   • Miner’s Certificate Number or Payroll Number: If applicable, include this information.
   • Language Preference: Indicate your preferred language (English/French).

Hearing Loss Details

1. • When did you first notice loss of hearing? Enter the date using (dd/mmm/yyyy).
   • Was the change in your hearing gradual or sudden? Specify if it was gradual or sudden.
   • When did you first seek medical attention for your hearing loss? Enter the date.
   • Are you bothered by ringing in your ears? Select Yes or No.
   • How long have you had ringing in your ears? Specify the duration.
   • Is the ringing constant and/or severe? Indicate if it is constant, severe, or both.
   • Do you have a hearing aid? Select Yes or No.
   • Have you ever been assessed by an Ear, Nose, and Throat specialist (ENT)? Select Yes or No.
   • If yes, provide the name, address, and phone number of the ENT specialist and assessment date.
   • When did you first receive hearing aids (if applicable)? Provide the date.
   • Have you ever had your hearing tested? Select Yes or No.
   • If yes, provide the name, address, and phone number of the clinic and test date.

Employment Status

1. • Are you currently employed? Select Yes or No.
   • If yes, provide the name, address, and phone number of your employer.
   • Do you still work in hazardous noise conditions? Select Yes or No.
   • Have you ever worked in an area where decibel (dB) levels were posted? Select Yes or No.
   • If yes, provide the name, address, and phone number of the employer and years worked and decibel level.
   • Have you ever worked in hazardous noise conditions outside of Ontario? Select Yes or No.
   • If yes, provide the name, address, and phone number of the employer and duration.
   • Are you retired? Select Yes or No.
   • If retired, provide the retirement date.
   • Do you or have you ever used noisy machinery, equipment, or firearms outside of work? Select Yes or No.
   • If yes, specify the type and frequency.
   • Have you ever been self-employed? Select Yes or No.
   • If yes, provide the name and address of the company and specify if you had personal coverage or optional insurance through WSIB.
   • Provide the start and end dates of your self-employment.

Section B: Noise Exposure Confirmation

References

1. • Provide the names, employers, and current or previous job titles of two people who can confirm your exposure to noise in the workplace.

Section C: Work History

Detailed Work History

1. • Start with your most recent employer and continue to your oldest.
   • For each employer, provide:
     • Employer’s name, address, and province.
     • Employment dates: From (dd/mmm/yyyy) to (dd/mmm/yyyy).
     • Job title.
     • Equipment used.
     • Exposure hours per day.
     • Ear protection used? Select Yes or No.
     • Where in the building were you exposed to noise?
     • Is the employer still in business? Select Yes or No.

Section D: Declaration and Consent

Agreement

1. • Read the declarations carefully.
   • Sign and date the form (dd/mmm/yyyy).
   • If submitting electronically, check the box and fill out your name and date.

Section E: Privacy Provisions

Privacy Information:

1. • Understand how your personal information will be used and disclosed.
   • For questions, contact the decision maker responsible for your file.

Submission Instructions

• Submit the completed form and any supporting documents online at wsib.ca.

By following these instructions, you can accurately complete and submit your Worker’s Report for Work-Related Noise-Induced Hearing Loss to the WSIB in Ontario.