2010 BC Guide in Determining Fitness to Drive

18.8 Hearing reportOffice of the Superintendentof Motor Vehicleswww.pssg.gov.bc.ca/osmvPO BOX 9254 STNPROV GOVTVICTORIA BC V8W 9J2Phone: (250) 387-7747Fax: (250) 952-6888HEARING REPORTNote to Driver: If you have had a hearing test done within one year prior to the date this form was issued, you maysubmit the results of that test. If you require a current hearing test to fulfill this requirement, OSMV will pay theservice provider directlyThe personal information on this form is collected under the authority of the Motor Vehicle Act and the Freedom of Information and Protection of Privacy Act. The information provided will beused to determine your fitness to drive a motor vehicle. Personal information is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection ofPrivacy Act and may be disclosed only as provided by that Act. If you have any questions about the collection, use and disclosure of the information collected, contact the Office of theSuperintendent of Motor Vehicles at (250) 387-7747.THIS REPORT MUST BE COMPLETED IN FULL AND RETURNED WITHIN 30 DAYS TO THE OFFICE OFTHE SUPERINTENDENT OF MOTOR VEHICLESDriver’s Name DL # Date IssuedRECENT UNAIDED AUDIOGRAMIntensity in Decibels(dB)RIGHTEARLEFTEARFREQUENCY IN HERTZ (Hz)500 1000 2000If hearing loss is greater than 40 dB in the better ear, complete the following:RECENT AIDED AUDIOGRAMIntensity in Decibels(dB)RIGHTEARLEFTEARFREQUENCY IN HERTZ (Hz)500 1000 2000224