Audiogram Form 
New Career Recruits
IMPORTANT PLEASE READ
1982 
Audiogram Form: Once completed, please forward this form with the invoice to:
Email: [email address]  or Fax: +64 4 471 1793
ACT 
Invoices: Please use ref: 5320/CFFRECRUT for invoices.
If you have any queries, please phone our Medical Screening Team on 04 496 3716.
Payment can only be made once Fire and Emergency New Zealand receives a completed copy of this form. 
Please retain a copy on the patient’s file.
First Name: ____________________________________  Last Name: _______________________________________ 
INFORMATION 
Date of birth (dd/mm/yy):   _______________________  Contact number: Mob (          )  _______________________
Audiogram - Audiologist to complete
OFFICIAL 
Does the candidate wear hearing aids? 
Yes  
 
No  
Normal hearing to conversation? 
Yes  
 
* No  
* If no, please provide previous hearing test
THE 
Has there ever been any hearing loss, or any problems with balance?  
* Yes
  No  
* If yes, please specify cause, treatment, concerns:
UNDER 
Speech distortion?
Yes  
 No  
Please provide a full audiogram including: 
• Pure tone audiometry
• Speech audiometry
• Immittance audiometry
RELEASED 
• Otoscopy
• Any further notes or recommendations
Audiogram Form | New Career Recruit | April 2021
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