Supervisor Verification of Experience

Name of Applicant:*

Last Name:*

Your Name:*

Company Affiliation:*

Address:*

City:*

State:*

Zip:*

Phone Number:*

Fax:

E-mail:*

Nature of Your Relationship to Applicant:*

Date-Frame of Verification:*

From

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: ____________

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: ____________

Supervisor Verification of Experience

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