F262-013-111 continuation emp history hearing loss continuation - lni wa 2026

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Click ‘Get Form’ to open it in the editor.
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, address, city, state, and phone number. Specify the employment duration using 'From' and 'To' dates.
Indicate the hours per week you were exposed to noise and describe your job duties along with any machinery or tools used.
Answer whether you were exposed to loud noise on this job. If yes, provide details about the noise source.
Specify if the noise was continuous or intermittent and indicate how many hours a day you were exposed to it.
Select the type of ear protection used during your employment and provide dates of any audiograms conducted while employed.
Finally, certify that all information is true by signing and dating the form before submission.

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