Audiometry Testing Report

AUDITORY TESTING

To be performed by an ENT specialist

Please attach audiometry graph

Certification

I have examined _______________________________________ and recommend the following:

[ ] Fit for umpiring with no restriction

[ ] Fit for umpiring subject to the following (state in comments space below)

[ ] Unfit for umpiring due to the reasons states below (in comments space)

Comments: ____________________________________________________________________

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Signed: Date:

Print Name: Dr. _________________________________________

Qualifications:

Address:

Phone No: Email: