F262-013-111 continuation emp history hearing loss continuation - lni wa 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your current job details, including your name, claim number, and start date of first employment. Fill in the employer’s business name and address, along with the job title and phone number.
3. Indicate the duration of noise exposure per week and describe your job duties, including machinery and tools used. Specify the percentage of time spent on these duties.
4. Answer whether you were exposed to loud noise during this job. If yes, provide details about the noise source and indicate if it was continuous or intermittent.
5. Document how many hours a day you were exposed to noise and what type of ear protection you used. Include any audiogram dates if applicable.
6. Repeat steps 2 through 5 for each prior employer as needed. Ensure all information is accurate before finalizing.
7. Finally, certify that the information provided is true by signing and dating the form.

Start using our platform today for free to streamline your form completion process!