NDIS Request for approval for devices to meet higher level needs Participant’s Name: NDIS Number: PURE TONE AUDIOMETRY 125 250 500 DATE: 1000 2000 4000 HEARING LEVELS IN DECIBELS (ISO STANDARD) 0 8000 0 10 10 20 20 30 30 40 40 50 50 60 60 70 70 80 80 90 90 100 100 110 110 120 120 125 250 Air: LEFT X Bone: UNMASKED Sound Field Thresholds (SPL): 500 1000 2000 FREQUENCY IN HERTZ RIGHT MASKED LEFT BINAURAL O ] 4000 8000 MASKED RIGHT [ What are the Participant’s detailed hearing goals? 1. 2. 3. 4. 5. Why are the OHS free-to-client devices not appropriate in this case? _______________________________________________________________________________________________ _______________________________________________________________________________________________ _________________________________________________________________________________________ What are the features of the recommended device that will help to meet the goals better than the free to client devices? _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Does the participant meet the OHS complex criteria? Yes / No (please circle) * Please attach the quote and return to the Planner for approval * National Disability Insurance Agency GPO Box 700, Canberra ACT 2601 Telephone 1800 800 110  Facsimile 02 6204 5058