Audiogram Form PDF Details

The Audiogram Form is a pivotal document officially recognized by both the International Committee of Sports for the Deaf (founded in 1924) and the International Olympic Committee, serving as a comprehensive tool for evaluating athletes' hearing capabilities. Housed at 528 Trail Avenue, Frederick, Maryland, and accessible through controls@ciss.org, this form meticulously records various hearing metrics including air and bone conduction frequencies, impedance tympanometry, and reflexometry, among others. It's mandatory for athletes aiming to participate in prestigious events like the Deaflympics, regional, and world championships to submit this form post completion by a qualified audiologist. The form mandates detailed inputs such as the type of audiometer used, calibration details, exhaustive hearing threshold levels across a wide range of frequencies, and identification of hearing loss type, which are essential for the accurate assessment of an athlete's hearing levels. Furthermore, it introduces a structured guideline for audiologists, emphasizing the importance of using the designated form downloadable from the Deaflympics website, and encompasses a stringent compliance to the testing protocols outlined, ensuring that each ear is evaluated across specified parameters. This not only aids in maintaining uniformity across evaluations but also helps in the identification and categorization of hearing loss, facilitating a fair and equal playing field for participants. The audiogram form stands as not merely a procedural necessity but a significant medium ensuring inclusivity and fairness in sports for the deaf, marking an essential step towards their participation in international sports events.

QuestionAnswer
Form NameAudiogram Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaudiogram template word, audiogram forms, blank audiogram pdf, audiogram template

Form Preview Example

Founded in 1924

International Committee of Sports for the Deaf

Recognized by the International Olympic Committee

OFFICIAL AUDIOGRAM DATA SHEET

528 Trail Avenue

Frederick, Maryland 21701

UNITED STATES

Fax: +1 301 620 2990

Email: controls@ciss.org

*Required Fields

 

PLEASE PRINT OR USE TYPEWRITER and send to your National Deaf Sports Federation for review

*Name:

 

 

 

 

 

 

 

Family Name (Last Name)

Given Name (First Name)

Other Names (Middle Name)

*Nation:

 

 

 

*Sport:

 

*Date of Birth:

 

 

*Which event?

Regional Championships

 

 

 

 

(day / month / year)

 

World Championships

*Gender:

Male

Female

 

Deaflympics

 

 

 

 

 

 

 

AUDIOGRAM

*Audiometer: *Calibration:

 

 

*Examiner Name:

 

ANSI 1969

I SO 1964

*Date of Examination:

 

Ot her:

 

 

(day / month / year)

 

*AIR CONDUCTION & *BONE CONDUCTION

 

 

FREQUENCY in hertz (Hz)

 

HEARING THRESHOLD LEVEL in decibels (dB)

125

250

500

1000

2000

4000

8000

0

10

20

30

40

50

60

70

80

90

100

110

120

KEY TO SYMBOLS

Ear

Air

Air-masked

Bone

Bone-masked

RIGHT (red)

O

<

[

LEFT (blue)

X

>

]

 

 

No Response

NR

 

 

 

 

 

 

*IMPEDANCE TYMPANOMETRY

Ear

 

Canal

Peak

Gradient

Pres.

 

 

Vol.

Comp.

 

Peak

RIGHT

 

 

 

 

 

 

 

 

 

 

LEFT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*REFLEXOMETRY

 

 

Side Equals Probe Ear

 

 

 

 

 

 

 

RIGHT

Stim

500

1000

2000

4000

 

Ipsi

 

 

 

 

 

 

 

 

 

Contra

 

 

 

 

 

 

 

 

 

 

LEFT

Stim

500

1000

2000

4000

 

Ipsi

 

 

 

 

 

 

 

 

 

Contra

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PURE TONE AVERAGE

 

 

(500-1000-2000 Hz)

 

 

 

 

 

Ear

 

Air

Bone

RIGHT

 

 

 

 

 

 

 

 

 

LEFT

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF HEARING LOSS

 

 

ICSD HOME OFFICE USE ONLY

 

 

(Check one for each ear with an "X")

 

 

ID:

 

 

Ear

Sensori-neural

 

Conductive

Mixed

Cochlear Implant

 

Data Entered By:

 

 

RIGHT

 

 

 

 

 

 

 

ICSD Audiologist:

LEFT

 

 

 

 

 

 

 

 

 

 

 

COMMENTS:

 

 

 

 

 

 

 

 

Audiogram Form

(In English)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised: 6 / 2011

www.deaflympics.com/forms/audiogram.pdf

*This field is required and audiogram form must be completed three (3) months before the event.

Notes for the audiologist:

Thank you for using the ICSD audiogram form. Our athletes need to complete this form fully to receive an Identification number to participate in upcoming Championship or Deaflympics events.

In compliance with ICSD audiogram regulations, here is a guideline for you to complete the ICSD audiogram form, as listed below:

1.Official ICSD Audiogram form must be used. The form can be downloaded from www.deaflympics.com/forms/audiogram.pdf

2.All four (4) types of audiogram testing below must be filled out entirely for EACH ear including:

1.

Air Conduction

-Please test on 500, 1000, and 2000Hz.

2.

Bone Conduction

-Please test on 500, 1000, and 2000Hz.

3.

Tympanograms (Tympanometry)

-Please write numbers

4.

Acoustic Reflexes (Reflexometry)

-Please write numbers or NR if there are no

responses. Do not use dash mark (-) or zero (0).

3.Below yellow box with numbers indicates required fields for you to enter:

1.Audiometer - Identify the name of the audiometer.

2.Examiner Name - Name of the audiologist who performs the test.

3.Calibration - Indicate the name of the calibration used.

4.Date of Examination - Enter examination date.

5.Air Conduction - Record air testing results. See 2.1

 

above. If there are no responses in Air Conduction,

1

 

 

 

 

please write NR as noted in “Key to Symbols”.

 

 

 

 

 

 

 

 

3

6.

Bone Conduction - Record bone testing results. See

 

 

 

 

 

 

 

2.2 above. If there are no responses in Bone

 

 

 

 

 

Conduction, please write NR as noted in “Key to

 

 

 

 

 

Symbols”.

 

 

 

 

7.

Tympanometry - Record Tympanometry test results.

 

 

 

 

 

See 2.3 above.

 

 

 

 

8.

Reflexometry - Record Reflexometry test results. See

5 & 6

2.4 above.

9.Pure Tone Average – Add 500, 1000, 2000Hz and divided by three (3) for both air and bone testing results.

10.Type of Hearing Loss - Identify the type of hearing loss by placing ‘X’ accordingly as shown on the form for respective ear.

11.Comments - Please write comments as needed about

 

 

 

this athlete. If there are no Tympanogram or reflex

 

 

 

equipments to test, please write comments in English.

 

 

 

12.This is for ICSD official uses only, do not write.

 

10

 

 

 

 

 

11

 

 

 

 

 

 

2

4

7

8

9

12

Failure to observe the requirements will result in delayed approval.

Thank you in advance for your cooperation,

ICSD Staff

As of: May 2011

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Part no. 1 of submitting blank audiogram pdf

2. When this array of fields is done, it's time to add the essential specifics in RIGHT Stim, Ipsi, Contra, LEFT, Stim, Ipsi, Contra, PURE TONE AVERAGE, Hz, Ear, Air, Bone, L E V E L D L O H S E R H T G N R, Ear, and RIGHT red so that you can proceed to the next part.

Find out how to fill in blank audiogram pdf portion 2

3. Completing COMMENTS In English, Audiogram Form Revised , wwwdeaflympicscomformsaudiogrampdf, and This field is required and is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Completing part 3 in blank audiogram pdf

Regarding This field is required and and Audiogram Form Revised , make sure you get them right in this section. These could be the key fields in this PDF.

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