RCMP Hearing Test Form PDF Details

The RCMP Hearing Test Form, officially known as RCMP GRC 3184e, is a comprehensive document used by the Royal Canadian Mounted Police to evaluate the auditory health of its employees and applicants. Filled with Protected B information once completed, this form serves multiple purposes, including the screening of new enrollees, periodic assessments of current personnel, and evaluations at the time of release. Individuals are required to provide personal details, employment history, and specifics regarding both occupational and non-occupational noise exposure, as well as a detailed medical history focusing on auditory health. The form also outlines the use and frequency of hearing protection devices, capturing data on exposure to various noise sources. Moreover, it includes a section for diseases or infections that might affect hearing capabilities, such as measles, cold/flu, and diabetes, among others. Applicants must sign a declaration and consent for the use of their information for pre-selection purposes, with a clear understanding that the cost of the examination and subsequent reports are their responsibility. The test results section mandates the completion by a certified examiner, who assesses whether the individual meets the RCMP's detailed hearing standards, which specify the acceptable levels of hearing loss across different frequencies. Ultimately, the RCMP Hearing Test Form is a pivotal tool in ensuring that members of one of Canada's premier national law enforcement services maintain the level of auditory health required for their demanding roles, embodying a blend of meticulous personal data collection and stringent auditory health standards.

QuestionAnswer
Form Name RCMP Hearing Test Form
Form Length 3 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 45 sec
Other names how to uptain a rcmp 6509 hearing test form, rcmp hearing, rcmp hearing and vision forms, rcmp grc 3184e

Form Preview Example

Screening Audiogram History

Personal Information

Protected B once completed

PIB CMP/P-PE 808

Date (yyyy-mm-dd)

Reg. No.

Surname

Given Names

Category of Employee

Regular Civilian Applicant

Rank

 

Age

Sex

 

Occupation

Time in This Occupation

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

Division

Detachment

 

 

Section

Cost Center (A9999)

 

 

 

 

 

 

 

 

General Information

Reason for this hearing test

Periodic

Enrolment

Release

Approximate Date of Last Hearing Test

(yyyy-mm-dd)

 

 

 

 

 

 

What type of hearing protection do you use?

Muffs

Plugs

Both

Other specify:

How often do you wear hearing protection?

Always

Mostly

Seldom

Never

Past Occupational Noise Exposure

Employer

Duration (in years)

Type of Noise Exposed to

Protection Used

Occupational Activities

Indicate, in years, which of the following you are presently being exposed to:

Small Arm

Explosive

Motorcycle

Computer

 

 

 

 

Rifle

Inside Aircraft

Outboard Motor

Traffic

 

 

 

 

Stun Grenade

Outside Airport

Snowmobile

Listening Device

 

 

 

 

Non-Occupational Activities

 

 

 

Indicate, in years, which of the following you are regularly doing or operating:

 

 

 

 

 

 

Active Military Duty

Artillery

Flying

Chainsaw

 

 

 

 

Hobby Shooting

Loud Music

Power Tools

Racing Cars

 

 

 

 

Power Mower

Scuba Diving

Musical Instrument

Heavy Equipment

 

 

 

 

Diseases or Infections

Do you have or have you ever had any of the following?

Measles

Mumps

Meningitis

High Fever

Cold / Flu

Other specify:

Kidney Disease High Blood Pressure

Diabetes Scarlet Fever

Allergies Recurring Sinusitis

Medical History

Do you have or have you ever had any of the following?

Ear Ache or Ear Infection

Severe Blow to the Head

 

Balance Problems

Excess Wax

Ear Surgery

Hearing Difficulties in Crowds

Hearing Difficulties

Dizziness

Ringing in Ears

Draining Ear

 

Skull Fracture

Hearing Aid

Abnormal Hearing Test

Examination by an Ear Specialist

Ruptured Ear Drum

Close Explosion or Blast

 

 

 

 

Has a close family member had hearing loss before the age of 50?

No

Yes his / her relationship is:

 

RCMP GRC 3184e (2016-05)

Page 1 of 3

Screening Audiogram History

Protected B once completed

Declaration and Consent for Applicants

For applicants only: I declare that the statements made to the Audiogram Examiner are complete and correct to the best of my knowledge and that I have not withheld any relevant information or made any misleading statements.

I consent that this information be provided to the Royal Canadian Mounted Police for pre-selection purposes.

The cost of this examination and reports prepared by the Examiner are my responsibility.

Signature of Applicant

Date (yyyy-mm-dd)

Employee Comments and Signature

Comments

 

Signature of Employee

Date (yyyy-mm-dd)

 

 

 

 

Recommendations

 

 

 

To be Completed on the Day of the Examination by the Tester

 

 

 

 

 

 

Time lapse since last noise exposure

24 hours or less

More than 24 hours

 

For applicants only

Please indicate if the applicant meets the following minimum RCMP Hearing Standards:

Hearing loss no greater than 30 dbs in the better ear in the 500 to 3000 Hz range.

Hearing loss no greater than 30 dbs in the worst ear in the range of 500-2900 Hz and no more than 50 dbs in the worst ear at 3000 Hz.

Meets or Exceeds

Does not meet

Not applicable

New Recommendations

 

 

Type of Audiometer

Examined by

Facility

Date of Test (yyyy-mm-dd)

RCMP GRC 3184e (2016-05)

Page 2 of 3

Screening Audiogram History

Protected B once completed

Audiometric Results

Name

Regimental Number

Date (yyyy-mm-dd)

Graphs and comments below are to be completed by professional examiner once form has been printed.

Comments

RCMP GRC 3184e (2016-05)

Page 3 of 3

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Filling out this document will require attentiveness. Make sure that every blank is filled out properly.

1. To start off, while filling out the RCMP Hearing Test Form, start out with the part with the following fields:

Step # 1 in filling out how to uptain a rcmp 6509 hearing test form

2. Now that the previous segment is complete, you're ready include the required details in Occupational Activities, Indicate in years which of the, Small Arm, Rifle, Stun Grenade, Explosive, Inside Aircraft, Outside Airport, NonOccupational Activities, Indicate in years which of the, Active Military Duty, Hobby Shooting, Power Mower, Artillery, and Loud Music allowing you to move on further.

how to uptain a rcmp 6509 hearing test form conclusion process explained (portion 2)

It is possible to make a mistake when filling out your Artillery, thus ensure that you reread it before you decide to finalize the form.

3. Completing Do you have or have you ever had, Ear Ache or Ear Infection, Severe Blow to the Head, Balance Problems, Ear Surgery, Ringing in Ears, Hearing Difficulties in Crowds, Hearing Difficulties, Draining Ear, Skull Fracture, Excess Wax, Dizziness, Hearing Aid, Abnormal Hearing Test, and Examination by an Ear Specialist is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

how to uptain a rcmp 6509 hearing test form completion process outlined (step 3)

4. This next section requires some additional information. Ensure you complete all the necessary fields - For applicants only I declare that, Employee Comments and Signature, Comments, Signature of Applicant, Date yyyymmdd, Signature of Employee, Date yyyymmdd, Recommendations, To be Completed on the Day of the, Time lapse since last noise, hours or less, and More than hours - to proceed further in your process!

how to uptain a rcmp 6509 hearing test form writing process clarified (stage 4)

5. To finish your document, this final part requires several additional blanks. Filling out Hearing loss no greater than dbs, Meets or Exceeds, Does not meet, Not applicable, New Recommendations, Type of Audiometer, Examined by, Facility, Date of Test yyyymmdd, RCMP GRC e, and Page of will certainly conclude the process and you're going to be done in a tick!

Learn how to fill in how to uptain a rcmp 6509 hearing test form stage 5

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