Physician assistants and workplace hearing tests

December 19, 2017

Jessica Alexander, PA-C, EMT-P

Fairweather LLC

[Recipient address omitted]

Dear Ms. Alexander:

Thank you for your letter to the Occupational Safety and Health Administration’s (OSHA) Directorate of Enforcement Programs. You requested clarification on who is allowed to interpret audiograms under OSHA’s occupational noise exposure standard, 29 CFR 1910.95. This letter constitutes OSHA’s interpretation only of the requirements herein, and may not be applicable to any questions not delineated within your original correspondence. Your paraphrased questions are presented below, followed by our responses.

Several provisions of the audiometric testing program in OSHA’s noise standard require specific duties to be performed by individuals with specific training, experience, or certification. In your letter, you state that you believe a Physician Assistant (PA) who is certified by the Council for Accreditation in Occupational Hearing Conservation (CAOHC), and who has been given the latitude by their supervising physician, should be able to interpret audiometric test results.

Question 1: Can a PA make the determination that a standard threshold shift (STS) has occurred?

Response: Section 1910.95(g)(7)(i) of OSHA’s noise standard states:

“Each employee’s annual audiogram shall be compared to that employee’s baseline audiogram to determine if the audiogram is valid and if a standard threshold shift as defined in paragraph (g)(10) of this section has occurred. This comparison may be done by a technician.”

Section 1910.95(g)(3) states: “Audiometric tests shall be performed by a licensed or certified audiologist, otolaryngologist, or other physician, or by a technician who is certified by the Council of Accreditation in Occupational Hearing Conservation, or who has satisfactorily demonstrated competence in administering audiometric examinations, obtaining valid audiograms, and properly using, maintaining and checking calibration and proper functioning of the audiometers being used. A technician who operates microprocessor audiometers does not need to be certified. A technician who performs audiometric test must be responsible to an audiologist, otolaryngologist or physician.”

Based on the language in the two paragraphs above, a PA can administer an audiometric test, and make a determination as to whether an STS has occurred, if that individual qualifies as a “technician.” Under Section 1910.95(g)(3), an individual qualifies as a technician by one of two methods. First, a person can complete a training course and become certified by CAOHC or a course given by another recognized training organization, and receive a certificate upon completion of the course. The second method involves demonstrating to the satisfaction of the professional supervisor of the hearing conservation program that competence in test administration and audiometer use has been achieved. See the March 8, 1983 preamble to OSHA’s final rule, Occupational Noise Exposure and Hearing Conservation Amendment, 48 Federal Register 9753-54.

Additionally, please keep in mind that Section 1910.95(g)(3) provides that a technician who performs audiometric tests must be responsible to an audiologist, otolaryngologist, or physician. This means that a PA who qualifies as a technician under the Noise standard can perform certain tasks if they are working under the license of a supervising audiologist, otolaryngologist, or physician.

Question 2: Can the PA recommend that the audiometric test be repeated after a 14-hour noise free period?

Response: Section 1910.95(g)(5)(iii) provides that a baseline audiogram must be preceded by at least fourteen (14) hours without exposure to workplace noise. There is no requirement for fourteen (14) hours without exposure to workplace noise for annual audiograms. If an annual audiogram indicates an STS, the employer may choose to retest within thirty (30) days, and this retest may be considered the annual audiogram. See, Section 1910.95(g)(7)(ii). Acting on behalf of the employer, a PA who qualifies as a technician can make the determination that a repeat annual audiogram is necessary.

Additionally, Section 1910.95(g)(7)(iii) provides that audiologists, otolaryngologists, or physicians must review problem audiograms to determine whether further evaluation is needed. Examples of “problem audiograms” which the reviewer may feel need further evaluation or retesting may include invalid audiograms, audiograms manifesting ear pathologies, audiograms that show large differences in hearing thresholds between the two ears, and audiograms that show unusual hearing loss configurations that are atypical of noise induced hearing loss. If a technician’s preliminary review of an audiogram indicates a problem audiogram, or an audiogram of questionable validity, the technician must refer the employee to the audiologist, otolaryngologist, or physician for further evaluation. See, 48 FR 9758-59. Under these circumstances, the supervising professional would be the one responsible for making the determination for a retest audiogram.

Question 3: Can a PA refer an employee to an audiologist to determine the source of an STS?

Response: As discussed above, qualified technicians are permitted to review typical or routine audiograms to determine whether an STS has occurred. When an audiogram indicates an STS, a PA who qualifies as a technician has the discretion to refer the employee to an audiologist for more detailed clinical assessment, provided the PA is working under the license of the supervising audiologist, otolaryngologist, or physician.

Question 4: Can the PA refer the employee to an Ear, Nose and Throat (ENT) specialist if there is a problem audiogram with an underlying medical problem?

Response: Section 1910.95(g)(8)(ii)(C) of the noise standard states: “The employee shall be referred for a clinical audiological evaluation or an otological examination, as appropriate, if additional testing is necessary or if the employer suspects that a medical pathology of the ear is caused or aggravated by the wearing of hearing protectors.” A PA who qualifies as a technician under Section 1910.95(g)(3) can make the referral to a specialist, including an ENT (i.e., otolaryngologist), provided the PA is working under the license of the supervising audiologist, otolaryngologist, or physician.

Thank you for your interest in occupational safety and health. We hope you find this information helpful. OSHA requirements are set by statute, standards, and regulations. Our letters of interpretation do not create new or additional requirements but rather explain these requirements and how they apply to particular circumstances. This letter constitutes OSHA's interpretation of the requirements discussed. From time to time, letters are affected when the Agency updates a standard, a legal decision impacts a standard, or changes in technology affect the interpretation. To assure that you are using the correct information and guidance, please consult OSHA's website at http://www.osha.gov.

If you have any further questions, please feel free to contact the Office of Health Enforcement at (202) 693-2190.

Sincerely,

Thomas Galassi, Director

Directorate of Enforcement Programs