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Confidential report from a hearing specialist
For example, from an Audiologist or Ear, Nose and Throat Specialist. Please return the completed form to your nearest Housing Service Centre.

Tenant to c	omplete				
I (name)	have no objection to the release of the information		
requested in this form to the Department of Housing for the purpose of determining installation of a suitable smoke alarm.		
Signature:		Date:			

Tenancy Reference Number:

Privacy Notice
The Department of Housing is collecting your personal information so we may provide you with housing assistance. To assist you with your housing needs and services, your personal information may be disclosed to partner agencies, service providers, local governments and non- governmental agencies that now, or will, provide you with housing and/or support services. Unless authorised or required by law, your personal information will not be disclosed to any other third party without your consent. More information about the Department’s privacy obligations is available on our website at www.housing.qld.gov.au.		

To the hearing specialist
The Department of Housing is installing smoke alarms in its properties as part of a Government initiative to increase safety. This form allows the department to determine if the standard alarm will meet the needs of your patient. We appreciate you taking the time to fill out the following on their behalf and returning it to allow appropriate action to be organised.
Information contained within this form is to be used as a guide only by the Department of Housing. All personal information provided in this form will be kept confidential and will not be disclosed to any unauthorised person.

Hearing specialist to complete		
Patient’s Name:		
		
Address:		
		
	Postcode:	
		
When was their last hearing assessment?		

1. Would a signal of 89dB at a frequency of 2kHz be audible to this person with wearing hearing aids?	
Yes	
No	
	Comments:				

2. Please indicate the degree of hearing impairment in the better ear.	
	Mild
3. Is the client’s condition:	Moderate to Severe	Severe to Profound	
		Permanent	Temporary	
		Improving	Other	
		Deteriorating		

4. If known, what other facilities would be required by this person?		

PLEASE USE BLOCK LETTERS or STAMP	
Name of Hearing	Speci	alist:					
							
Address:							

Telephone:							
							
Fax:							
							
Email:							
							
Signature:						Date:	

Please return the completed form to your nearest Housing Service Centre