DD Form 2215: Reference Audiogram

In Box 1, enter nine digit ZIP Code/APO/FPO/PAS of where audiometric test is conducted.

In Box 2, enter the letter of the major organizational subdivision of DoD to which the military or civilian individual is assigned. Enter "1" if the component is not listed.

In Box 3, enter the letter in box corresponding to the primary subdivision of the separate military service in which the military is assigned: Regular (R), the standing military component of armed forces in peace and war; Reserve (V), the component of ready trained personnel for military service when needed; National Guard (G), the component of National Guard personnel in full-time or part-time status. Enter "1" for all others, including civilians.

In Box 4, enter ten digit DoD ID number.

In Box 5, enter surname, given name and middle initial.

In Box 6, enter year, month, day, as YYYYMMDD.

In Box 7, enter "M" if male, "F" if female.

In Box 8, pay grade, uniformed services: for military personnel only, enter military personnel class and pay level serial number.

In Box 9, grade, civilian: enter two letters and two numbers of Federal civilian employee rank (e.g., WG05, GS11, etc.). Letter entries will be WG, WL, WS, WN, WD or GS. Number entries will be 01 to 18. Enter "1111" if other (e.g., foreign national, contractor, etc.).

In Box 10, enter code to which military member's duty occupation is assigned (e.g., MOS, SSI, NEC/Rating, NOBC or AFSC in which individual is actually working).

In Box 10, enter number code of civilian job series in which civilian member is actually working (e.g., for a carpenter enter "4607").

In Box 11, enter installation name (and street address for Navy and Marines), unit, office symbol, and ZIP Code/APO/FPO/PAS of individual's current duty assignment.

In Box 12, enter specific location where individual is routinely exposed to hazardous noise including building number (e.g., Corpus Christi, NAS, Building 1571, Carpenter Shop).

In Box 12, for Air Force personnel, enter 12-digit Workplace Identifier Code per AFOSH Std. 161-17.

In Box 13, enter authorized abbreviation of military major command to which individual is assigned.

In Box 14, enter individual's duty telephone number, including area code.

In Box 15, enter number in box for reason to complete reference audiogram. Enter 1 if individual has not yet worked in hazardous noise duty areas and no reference audiogram has been accomplished. Enter 2 if individual has worked in hazardous noise duty areas but reference audiogram has been lost or was never accomplished. Enter 3 if individual has worked in hazardous noise duty areas and requires revised reference audiogram following completion of hearing conservation follow-up program.

In Box 16, enter threshold levels determined for this individual at six frequencies in each ear. Results are entered in 5dB increments (e.g., 0, 5, 10, 15, etc). If responses exceed maximum limits of audiometer, enter that limit with plus sign (e.g., 110+).

In Box 17, date of audiogram: enter year, month, and day the audiometric test is given. If January 14, 1999, enter 19990114.

For Box 18, meets referral criteria: based on the audiometric test results, each DoD component should apply its own criteria.

In Box 19, enter four digits for hour of day (24-hour clock) this audiogram is completed (e.g., "0830," "1400," etc.). This field is optional.

In Box 20, hours since last noise exposure: enter appropriate number of hours prior to this audiogram that individual was last exposed to hazardous noise (e.g., steady noise 85 dBA or greater and/or impulse noise above 140 dBP).

In Box 21, enter "1" (NO) if individual has no ear, nose or throat problems at time of test that could be causing a temporary (conductive) hearing loss (e.g., ear canal blocked with ear wax, ear infection, head cold, etc.). Enter "2" (YES) if problem was present and "3" (UNKNOWN) if no way to determine presence of problem.

In Box 22a, enter surname, given name and middle initial of individual operating audiometer.

In Box 22b, enter audiometric technician training certification number.

In Box 22c, enter examiner's service duty occupation code (see Item 10).

In Box 22d, enter complete office symbol where examiner is performing the test.

In Box 23a, enter number for type of audiometer used (e.g., "1" for manual type).

In Box 23b, enter manufacturer's designation.

In Box 23c, enter name of company that produced audiometer.

In Box 23d, enter manufacturer's serial number.

In Box 23e, enter year, month and day (see Item 16) of last electroacoustic determination of this audiometer's performance specifications.

In Box 24a, personal hearing protection type issued: enter number for type of hearing protector that the individual was issued (e.g., "2" for triple flange, etc.; if "6 - OTHER," explain in Item 25, "Remarks").

In Box 24b, enter number for size of earplugs (single or triple flange) used for each ear (e.g., "4" for Large in right ear (R) and "3" for Medium or Regular in left ear (L)).

In Box 24c, enter "1" in box if earplugs are not routinely worn in combination with noise muffs or a noise-attenuating helmet. Enter "2" if they are routinely worn together.

In Box 24d, enter "1" in box if eye glasses or goggles are not routinely worn with noise muffs or noise-attenuating helmet.

In Box 24e, indicate frequency of use if "2" was entered in Item 24.d. If "1" was entered in 24.d., enter "3" - N/A.

In Box 25, print explanations for any of above items marked "OTHER" and any information considered pertinent. Include the individual's 8-hour TWA noise exposure, when available.