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Employer Report of Occupational Hearing Loss. Instruction. Complete this form if an employee experiences occupational noise-induced hearing loss.There were 14500 workrelated hearing loss illness cases in 2019. They occurred at a rate of 1. 4 Hearing impairment is hearing loss that impacts day-to-day activities. Section 1904. This completed form within 30 days. "The first step is always using stateissued paperwork to file a formal claim with the employer where the injury occurred," Frantz says. Give date you first related hearing loss to employment, and reason why. Please complete in triplicate (type if possible) Mail two copies to: OSHA CASE NO. FATALITY.