What the 1787A is for
The ENT Consultation Report records a specialist’s assessment of a worker’s hearing loss, dizziness, balance problem or tinnitus for WSIB. It is most often used on noise-induced hearing loss claims, where WSIB needs to see how long and how loudly the worker was exposed at work, what else could explain the loss, and what the audiograms show.
It doesn’t replace the family physician’s Form 8 on a new injury claim. It is the specialist’s consultation report on the hearing complaint.
Who completes it
The otolaryngologist completes the whole form and signs the billing section. The worker has no part to fill in, though most of the history comes from them.
How to fill in the report
Complaints and occupational noise exposure
Tick hearing loss, dizziness, balance or tinnitus, and say how long, whether it’s constant or intermittent, and whether it disturbs sleep. Describe the type of work, the hearing protection used, and the number of years of exposure. Record noisy hobbies such as hunting or snowmobiling, and for guns, the type, years, which shoulder and rounds per year.
Medical history
List ototoxic medications, head injuries, family history, allergies and ear surgery. These are the other possible causes of hearing loss, so answer each one, even when the answer is none.
On examination
Answer yes or no for normal external auditory canals, tympanic membranes and middle ear clefts. Confirm that audiograms with readings at 500, 1000, 2000 and 3000 Hz are enclosed, along with any previous assessments and audiograms.
Diagnosis/findings and billing
Give your diagnosis and findings, then other conditions and investigations. Complete your name, health card number, WSIB provider number, invoice number and HST details, and sign, or tick the electronic signature box and add your name and the date.
Common reasons it’s queried
- No audiograms enclosed, or audiograms missing the required frequencies.
- An exposure history with no years of exposure or hearing protection.
- Non-occupational noise, such as firearms, left blank.
- Ototoxic medications or head injuries not addressed.
- A consultation report billed without a consultation visit.
Submitting and who pays
Submit the form and enclosures at wsib.ca/submit, or fax or mail them to the numbers and address on the form. WSIB pays the consultation report fee, and the M650 copy fee for enclosed previous reports and audiograms, so the worker isn’t billed.