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CAOHC

Supervisor Verification of Experience

Name of Applicant:*
Your Name:*
Company Affiliation:*  
Address:*
City:*
State:* 
Zip:*  
Phone Number:*
Fax:
E-Mail:*
Nature of Your Relationship to Applicant:*
Date-Frame of Verification:* From to
Nature of applicant's occupational hearing conservation responsibilities during this time frame:*

Number of hours applicant devoted to hearing conservation per month
during this time frame:*

You may count hours from the following areas:
1) Noise hazard identification and evaluation
2) Engineering noise control development or evaluation
3) Hearing protection devices
4) Audiometric testing (excluding hearing aid or surgery evaluations)
5) Hearing conservation education/training
6) Audiometric review and follow-up for hearing conservation programs
7) Hearing conservation program evaluation & management

Additional comments:

* I verify, to the best of my knowledge, that the above information is true and accurate.

Signature (if mailing or faxing form):______________________________________________

Date: ____________

* indicates required field

Submit form online or print and mail or fax to:

CAOHC
555 E. Wells Street, Suite 1100, Milwaukee, WI 53202-3823
Phone: 414/276-5338    Fax: 414/276-2146      info@caohc.org

 

FOR OFFICE USE ONLY: 
 Rec'd @ CAOHC Office:

Signature: ____________________________________________ Date: ____________