DD Form 2215: Reference Audiogram

DD Form 2215 PDF Details

Enter threshold levels determined for this individual at six frequencies in each ear.

Results: results are entered in 5dB increments (e.g., 0, 5, 10, 15, etc).

Maximum limits: if responses exceed maximum limits of audiometer, enter that limit with plus sign (e.g., 110+).

Hours since last noise exposure: enter appropriate number of hours prior to this audiogram that individual was last exposed to hazardous noise.

Meets referral criteria: based on the audiometric test results, each DoD component should apply its own criteria.

Name: enter surname, given name and middle initial of individual operating audiometer.