AUDIOLOGIST CONFORMITY EVALUATION

AUDIOLOGIST CONFORMITY EVALUATION

Michigan Department of Labor and Economic Opportunity Michigan Rehabilitation Services
Customer's Name
MRS Counselor Name
Office Address
To be completed by the Audiologist to ensure fit and function
Hearing Aid Make and Model:
Right
Left
Dispensing Date:
Right
Left
Conformity Evaluation Date

MonthDayYear
Date
Audiologist’s Name
Ear Mold Fitting
Hearing Aid Fitting
Hearing Aid Special Features
How has speech recognition improved?
Were any adjustments made at conformity evaluation?
If yes, what adjustments were made?
Comments
Certified Audiologist’s Signature
The Michigan Department of Labor and Economic Opportunity (LEO) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

MRS-68a (Rev 3-2020) -- Previous edition obsolete.
Should be Empty: