Workers' Compensation and Rehabilitation Amendment Regulations 1992 (WA)
3 April 19921 GOVERNMENT GAZETTE, WA 1541 WC302 WORKERS' COMPENSATION AND REHABILITATION ACT 1981
WORKERS' COMPENSATION AND REHABILITATION
AMENDMENT REGULATIONS 1992
Made by His Excellency the Governor in Executive Council.
Citation
1. These regulations may be cited as the Workers' Compensation and Rehabili-
tation Amendment Regulations 1992.
Principal Regulations
officer completes the audiometric test;
2. In these regulations the Workers' Compensation and Rehabilitation Regula-
tions 1982* are referred to as the principal regulations.
[k Published in the Gazette of 8 April 1982 at pp. 1229-50.
For amendments to 18 February 1992 see 1990 Index to Legislation of Western
Australia, pp. 422-3 and Gazettes of 26 January, 8 March and 28 June 1991.]
Regulation 19C amended3. Regulation 19C of the principal regulations is amended—
(a) by repealing subregulation (7) and substituting the following subregu- lation— (7) Where an initial audiometric test is carried out by an audiometric officer and the results of an air conduction test meet the criteria specified in Item 1, 2 or 3 of Waugh and Macraes' criteria for medical referral in Table 1 of National Acoustic Laboratories Report No. 80, the audiometric officer shall refer the worker to an audiologist or an approved medical practitioner for full audiometric testing. ";
and
(b)
in subregulation (10) by deleting paragraphs (a) and (b) and substitut- ing the following paragraphs-
(a) if the referral is under subregulation (6), the audiometric
| 1542 | GOVERNMENT GAZETTE, WA | [3 April 1992 |
(b) if the referral is under subregulation (7), the medical practitio- ner or audiologist completes the audiometric test; and (c)
if the referral is under subregulation (8) or (9), the medical practitioner or audiologist completes the audiometric test, or if the worker is further referred, the medical practitioner registered in the speciality of otorhinolaryngology determines the percentage of noise induced hearing loss. ".
Appendix 1 amended
4. Appendix 1 to the principal regulations is amended by deleting Forms 19Aand 19B and substituting the following forms—
FORM 19A
(Reg. 19F)
WORKERS' COMPENSATION AND REHABILITATION ACT 1981
REPORT OF BASELINE AUDIOMETRIC TEST
TO: EXECUTIVE DIRECTOR, WORKERS' COMPENSATION AND
REHABILITATION COMMISSION
Notice is hereby given that I have conducted an audiometric *test/retest of:
WORKERS' DETAILS
GIVEN NAMES (in fufl)
1:1 SEX
I IIHIIIHIHIIIHHIHIJ LII
M F
SURNAME
ADDRESS NUMBER AND STREET
I I I I I I I I I I I I I I I I I I I I I I I I I I I 1 1 -1 I I I I
SUBURB OR TOWN POST CODE DATE OF BIRTH
I I I I I I I I I
I A 1711
DAY MONTH YEAR HOME PHONE NUMBER WORK PHONE NUMBER
A.S.C.O-OFFICE USE
OCCUPATION OF WORKER
EMPLOYED BY:
r1 111111111111 I I I I 1111111111111 I I I Ii FULL NAME OF EMPLOYER
I I I I I I I I I I I I I I I I I I I I II ADDRESS NUMBER AND STREET OF EMPLOYER
I I I I I j I I I I I I I I I I I I I I I I I I I I I I I J= SUBURB OR TOWN POST CODE
A.S.C.O..OFFICE USE
PREDOMINANT INDUSTRY OF EMPLOYER
LEVEL OF TEST: PURPOSE OF TEST:
I I
Air-conduction Baseline I
Full audiological
Medical Panel
3 April 19921 GOVERNMENT GAZETTE, WA 1543 WAUGH AND MACRAES' CRITERIA:
(Please tick only if worker fails)
Item 1 Item 2 Item 3 HEARING TEST RESULTS
HERTZ (Hz) 500 1000 1500 2000 3000 4000 6000 8000 RT EAR
RT EAR MASKED
AIR
CONDUCTION
LT EAR
LT EAR
" MASKED RTEAR
BONE
CONDUCTIONRT EAR MASKED
LT EAR
LT EAR
MASKEDCALCLJLATEDPLH I
OFFICE USE
PERSON CONDUCTING TEST __ _
I I I I I I I I I I I I I I I
SURNAME INITIALS REG. NO.
EQUIPMENT REG. NO. BOOTH REG. NO.
I I
I hereby certify, that I have personally conducted an audiometrictest in accordance with the Workers Compensation and Rehabilitotion
Act 2982 and to the best of my knowledge and belief the results are true and correct-
DATE OF TEST
SIGNATURE
• Delete which doesn't apply
Approved Medical Practitioners or Audiologists Only DAY MONTH YEAR
| 1544 | GOVERNMENT GAZETTE, WA | [3 April 1992 |
FORM 19B
(Reg. 19F)
WORKERS' COMPENSATION AND REHABILITATION ACT 1981
REPORT OF SUBSEQUENT/RETIRING/TURNING 65
AUDIOMETRIC TEST
TO: EXECUTIVE DIRECTOR, WORKERS' COMPENSATION AND
REHABILITATION COMMISSION
Notice is hereby given that I have conducted an audiometric *testjretest of: WORKERS' DETAILS
I I I I I I I I I I I I I I I I I I I I I I GIVEN NAMES (in lull) SEX [I]
SURNAME M F
FORMER SURNAME IF APPLICABLE I I I I I I I I I I I I I I I I I I I I
I I I I I I I I I I I I I I I I I I I I I I I I I I I I ADDRESS NUMBER AND STREET
I I I I I I I I I
I I I I I I I I I I I I
SUBURB OR TOWN POST CODE DATE OF BIRTH
I I I I HI III I 111111 E] I I II I II I I]
DAY MONTH YEAR HOME PHONE NUMBER WORK PHONE NUMBER
I I I I
A.S.C.O.-OFFICE USE
OCCUPATION OF WORKER
EMPLOYED OR FORMERLY EMPLOYED BY:
FULL NAME OF
I I I I I I I I I I I I I I I I I I I I I I II
ADDRESS NUMBER AND STREET OF EMPLOYER
I I I I I I I I I I I I I I I I I I I I I I I I I I II
SUBURB OR TOWN POST CODE
I I I I I
A.S.C.O.-OFFICE USE
PREDOMINANT INDUSTRY OF EMPLOYER
LEVEL OF TEST: PURPOSE OF TEST: Air-conduction Full audiological Subsequent Medical Panel Retired/Turning 66
3 April 19921 GOVERNMENT GAZETTE, WA 1545 REARING TEST RESULTS
I HERTZ (Hz) I 500 I i000 1 1500 1 2000 1 3000 1 4000 s000 J 8000 RT EAR
RT EAR MASKED
AIR
CONDUCTION LT EARLT EAR MASKED
RT EAR
RT EAR MASKED
00
BONE - CONDUCTION LT EAR 1 LT EAR MASKED
OTORHINOLARYNGOLOGICAL EXAMINATION
CALCULATED Put
I I I
OFFICE USE Practitioner................................................................... Addreo ....................................................................
CALCULATED NOISE INDUCED PLH SINCE BASELINE TEST/PREVIOUS ELECTION
Signature............................................. Date...............
PERSON CONDUCTING TEST
SURNAME INITIALS KEG. NO.
EQUIPMENT ERG. NO. BOOTH EEC. NO.
I hereby certify, that I have porconzilly conducted an audiometricteot inaccordanco with the Worlcera'Compenaoiioa and licha bili lotion f Act 1981 and to the beat of my knowledge and belief the reaulta are true and correct.
DATE OF TEST
SIGNATURE
Delete which dowm't apply
Approved Medical Practiti0000ru orAudialogtoto Only H Regiotered Otorhinolo,ynoIo3iot Only DAY MONTH YEAR
By His Excellency's Command,
D. C. BLIGHT, Clerk of the Council.
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