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*

SatisfactoryUnsatisfactory
Hearing Aid Fitting*

SatisfactoryUnsatisfactory
Hearing Aid Special Features*

SatisfactoryUnsatisfactory
How has speech recognition improved?*
Were any adjustments made at conformity evaluation?*

YesNo
If yes, what adjustments were made?
Comments
Certified Audiologist’s Signature*

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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.
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