Jul, 2026 14:31 (UTC-07) "From: WWW.FAX.PLUS (mark heland)

Yo: +16042327787 «dL 1 of 2

REVIEW DIVISION SUBMISSION

Review Division
Review Number:
Send this form via mail or fax. We only require one form. R0360901
Retum to: Review Division Phone: 604 214-5411
WorkSafeBc. Toll Free Phone In B.C. 1 888 922-8804
PO Box 2071 Stn Terminal Fax: 604 232-7747 Toll Free Fax in B.C. 1 855-433-9728
Vancouver BC V6B 3S3 www, worksafebc.com
A._ Review information
| Applicant name Mark Holand

Decision date under review March 23, 2026

B. File information received & complete?
Please check (>”} al that apply.

{ have receved copies of the Board records that were sent to mez
File number(s): _ 42647461

“if you have not recelved copies of all files indicated above within 14 days of the date of the atiached caver letter,
please contact the Disclosures Department at 604-279-7607 of toll frae 4-888 967-5377, focal 7607 immediately.

(7 i nave read the records that were sent to me and believe they ere compiate.

C1 thave read the records that were sent to me and wish to withdraw my request for review.

(3 | have read the records that were sent to me and betieve that they are missing the following documents:
(Please describe. Atiach separate sheet if necessary. )

L

G._What Is the resuit you want from this review?
Please check (*) one only.

G same as on my request for review form, OR
rf would like. .(please explain)

| request the Review Division set aside the March 20, 2026 Clinical Opinion and
refer this claim for a fresh medical opinion informed by the attached
specialist evidence, rather than audiological criteria alone.

@G3M5 0202) Page 1 of 2 Plezse continue on raverse side

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