Dd 2215 Form PDF Details

The DD Form 2215, also known as the Reference Audiogram, plays a crucial role within the framework of the United States Department of Defense's health monitoring and preservation efforts, particularly relating to hearing conservation. At its core, this form is utilized to establish a baseline for an individual's hearing ability. This is notably significant for personnel who are regularly exposed to hazardous noise levels, whether in training or operational environments. The form meticulously records an array of personal data, including the individual's service component, social security number, branch, rank, and detailed audiometric data aligned with ANSI S3.6 - 1989 standards. It is intricately designed to capture the left and right ear hearing thresholds at multiple frequencies, providing a comprehensive overview of an individual's hearing status. This process is fundamental for initiating effective hearing conservation programs, facilitating the monitoring of hearing levels over time, and identifying any deteriorating hearing ability at the earliest possible stage. Additionally, the DD Form 2215 serves as a privacy-protected document, ensuring that sensitive personal information is adequately safeguarded in accordance with the Privacy Act of 1974. Its structured format includes provisions for noting the type of personal hearing protection issued and its use, alongside other critical data related to the examination conditions and the examiner's credentials, making it a comprehensive tool for both initial and reference audiometric assessments within the Department of Defense.

QuestionAnswer
Form NameDd 2215 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesthe form 2215, you dd 2215 get, you dd 2215 form, you form 2215

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REFERENCE AUDIOGRAM

(This f orm is subject t o t he Privacy Act of 1974 - use Blanket PAS - DD Form 2005)

1 . ZIP CODE/APO/FPO/PAS

2 . DOD COM PONENT

3 . SERVICE COM PONENT

 

A - ARMY

F - AIR FORCE

1 - OTHER

 

R - REGULAR

G - NATIONAL GUARD

 

 

 

N - NAVY

M - MARINE CORPS

 

 

V - RESERVE

1 - OTHER

 

 

 

 

 

 

 

 

 

 

4 . SOCIAL SECURITY NUM BER

5 . NAM E (Last , First , Middle Init ial)

 

6 . DATE OF BIRTH

7 . SEX

 

 

 

 

 

 

 

(YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

M - MALE

 

 

 

 

 

 

 

 

 

F - FEMALE

8 . PAY GRADE,

9 . PAY GRADE, 1 0 . SERVICE DUTY

1 1 . M AILING ADDRESS OF ASSIGNM ENT

UNIFORM ED

CIVILIAN

OCCUPATION CODE

 

SERVICES

 

 

 

 

 

 

 

 

1 2 . LOCATION - PLACE OF WORK

1 3 . M AJOR COM M AND

1 4 . DUTY TELEPHONE (Include area code)

AUDIOM ETRY

1 5 . REASON FOR CONDUCTING AUDIOGRAM

 

 

 

1 - REFERENCE ESTABLISHED PRIOR TO

2 - REFERENCE ESTABLISHED FOLLOWING

3 - REFERENCE RE-ESTABLISHED AFTER

 

 

INITIAL DUTY IN HAZARDOUS NOISE AREAS

EXPOSURE IN NOISE DUTIES

FOLLOW-UP PROGRAM

 

 

 

 

1 6 . AUDIOM ETRIC DATA RE: ANSI S3 .6 - 1 9 8 9

1 7 . DATE OF AUDIOGRAM

(YYYYMMDD)

 

 

 

LEFT

 

 

 

 

RIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

500

1000

2000

 

3000

4000

6000

500

1000

2000

3000

4000

6000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 8

. M EETS REFERRAL CRITERIA

1 9 . M ILITARY TIM E OF DAY

2 0 . HOURS SINCE LAST

2 1 . EAR, NOSE, AND THROAT PROBLEM

 

 

1

- NO

(Opt ional)

NOISE EXPOSURE

 

AT TIM E OF TEST

 

 

 

 

 

 

 

1 - NO

2 - YES

3 - UNKNOWN

 

 

2

- YES

 

 

 

 

 

 

 

 

 

 

 

 

 

2 2

. EXAM INER

 

 

 

 

 

 

 

 

 

 

 

 

 

A. NAM E (Last , First , Middle Init ial)

 

B. TRAINING CERTIFICATION

C. SERVICE DUTY

 

D. OFFICE SYM BOL

 

 

 

 

 

NUM BER

 

OCCUPATION CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

2 3 . AUDIOM ETER

A. TYPE

B. M ODEL

C. M ANUFACTURER

D. SERIAL NUM BER

1 - MANUAL

2- SELF-RECORDING (Aut omat ic)

3- MICROPROCESSOR

E. LAST ELECTROACOUSTIC CALIBRATION DATE

(YYYYMMDD)

2 4 . PERSONAL HEARING PROTECTION

A. TYPE ISSUED

4

- EAR CANAL CAPS

B. SIZE EARPLUGS

C. DOUBLE

D. GLASSES WORN

E. FREQUENCY GLASSES

 

 

 

 

 

 

 

 

PROTECTION

 

(Including goggles)

 

WORN

 

1

- SINGLE FLANGE (VS1R)

5 - NOISE MUFFS

 

 

 

 

 

 

 

 

 

 

 

 

 

USED

 

 

 

 

L R 1 - XS

4 - L

 

 

 

 

1

- ALWAYS

 

2

- TRIPLE FLANGE

6

- OTHER

 

 

 

 

 

 

 

 

 

2

- S

5 - XL

 

1

- NO

 

 

1 - NO

 

2

- SELDOM

 

3

- HAND FORMED EARPLUG

7

- NONE

 

 

3

- M

 

 

2

- YES

 

 

2 - YES

 

3

- N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2 5 . REM ARKS (Include exposure dat a)

DD FORM 2 2 1 5 , JAN 2 0 0 0

PREVIOUS EDITION MAY BE USED.

INSTRUCTIONS

(Ref er t o DoD Component Inst ruct ions f or addit ional guidance)

PURPOSE: This f orm is used t o record init ial audiomet ric t est result s w it h w hich lat er audiomet ric t est result s can be compared (see DD Form 2216, " Hearing Conservat ion Dat a," t o record periodic t est result s).

1 . ZIP CODE/APO/FPO/PAS. Ent er nine digit ZIP Code/APO/FPO/ PAS of w here audiomet ric t est is conduct ed.

2 . DOD COM PONENT. Ent er let t er in box of major organizat ional subdivision of DoD t o w hich milit ary or civilian individual is assigned. Ent er " 1" if DoD component is not list ed.

3 . SERVICE COM PONENT. Ent er let t er in box corresponding t o primary subdivision of separat e milit ary service in w hich milit ary is assigned (e.g., Regular (R) - st anding milit ary component of armed f orces in peace and w ar; Reserve (V) - component of ready t rained personnel f or milit ary service w hen needed, et c.; Nat ional Guard (G) - component of Nat ional Guard personnel in f ull-t ime or part -t ime st at us). Ent er " 1" f or all ot hers, including civilians.

PERSONAL DATA OF INDIVIDUAL BEING TESTED:

4 . SOCIAL SECURITY NUM BER. Ent er nine digit social securit y number. If f oreign nat ional, ent er " FN" in middle t w o blocks.

5 . NAM E. Ent er surname, given name and middle init ial.

6 . DATE OF BIRTH. Ent er year, mont h, day.

7 . SEX . Ent er " M" if male, " F" if f emale.

8 . PAY GRADE, UNIFORM ED SERVICES. For milit ary personnel only, ent er milit ary personnel class and pay level serial number as f ollow s:

O11 - General of t he Army/General of t he Air Force/Fleet Admiral O10 - General/Admiral

O09 - Lieut enant General/Vice Admiral

O08 - Major General/Rear Admiral (Upper Half )

O07 - Brigadier General/Rear Admiral (Low er Half )/Commodore

O06 - Colonel (A,F,M)/Capt ain (N)

O05 - Lieut enant Colonel/Commander

O04 - Major/Lieut enant Commander

O03 - Capt ain (A,F,M)/Lieut enant (N)

O02 - First Lieut enant /Lieut enant Junior Grade

O01 - Second Lieut enant /Ensign W05 - Chief Warrant Of f icer, W-5 W04 - Chief Warrant Of f icer, W-4 W03 - Chief Warrant Of f icer, W-3 W02 - Chief Warrant Of f icer, W-2 W01 - Warrant Of f icer, W-1 C00 - Cadet /Midshipman

E09 - Sergeant Major/Chief Mast er Sergeant /Mast er Chief Pet t y Of f icer E08 - Mast er Sergeant (A,M)/Senior Chief Pet t y Of f icer/Senior

Mast er Sergeant /First Sergeant (A)

E07 - Sergeant First Class/Gunnery Sergeant /Chief Pet t y Of f icer/

Mast er Sergeant (F)/Plat oon Sergeant (A)/Specialist -7

E06 - St af f Sergeant /Technical Sergeant /Pet t y Of f icer First Class/ Specialist -6

E05 - Sergeant (A,M)/St af f Sergeant /Pet t y Of f icer Second Class/ Specialist -5

E04 - Corporal/Sergeant (F)/Pet t y Of f icer Third Class/Specialist -4

E03 - Privat e First Class (A)/Airman First Class/Lance Corporal/Seaman E02 - Privat e (PV1)/Airman/Privat e First Class (M)/Seaman Apprent ice E01 - Privat e (PV2)/Privat e (M)/Airman Basic/Seaman Recruit

9 . GRADE, CIVILIAN. Ent er t w o let t ers and t w o numbers of Federal civilian employee rank (e.g., WG05, GS11, et c.). Let t er ent ries w ill be WG, WL, WS, WN, WD or GS. Number ent ries w ill be 01 t o 18. Ent er " 1111" if ot her (e.g., f oreign nat ional, cont ract or, et c.).

1 0 . SERVICE DUTY OCCUPATION CODE. Ent er code t o w hich milit ary member' s dut y occupat ion is assigned (e.g., MOS, SSI, NEC/Rat ing, NOBC or AFSC in w hich individual is act ually w orking). Ent er number code of civilian job series in w hich civilian member is act ually w orking (e.g., f or a carpent er ent er " 4607" ).

1 1 . M AILING ADDRESS OF ASSIGNM ENT. Ent er inst allat ion name (and st reet address f or Navy and Marines), unit , of f ice symbol, and ZIP Code/APO/FPO/PAS of individual' s current dut y assignment .

1 2 . LOCATION - PLACE OF WORK. Ent er specif ic locat ion w here individual is rout inely exposed t o hazardous noise including building number (e.g., Corpus Christ i, NAS, Building 1571, Carpent er Shop). For Air Force personnel, ent er 12-digit Workplace Ident if ier Code per AFOSH St d. 161-17 .

1 3 . M AJOR COM M AND. Ent er aut horized abbreviat ion of milit ary major command t o w hich individual is assigned.

1 4 . DUTY TELEPHONE. Ent er individual' s dut y t elephone number.

AUDIOM ETRY:

1 5 . REASON FOR CONDUCTING AUDIOGRAM . Ent er number in box f or reason t o complet e ref erence audiogram.

1- Individual has not yet w orked in hazardous noise dut y areas and no ref erence audiogram has been accomplished.

2- Individual has w orked in hazardous noise dut y areas but

ref erence audiogram has been lost or w as never accomplished.

3- Individual has w orked in hazardous noise dut y areas and requires revised ref erence audiogram f ollow ing complet ion of hearing conservat ion f ollow -up program.

1 6 . AUDIOM ETRIC DATA RE: ANSI S3 .6 - 1 9 8 9 . Ent er t hreshold levels det ermined f or t his individual at six f requencies in each ear. Result s are ent ered in 5dB increment s (e.g., 0, 5, 10, 15, et c). If responses exceed maximum limit s of audiomet er, ent er t hat limit w it h plus sign (e.g., 110+ ).

1 7 . DATE OF AUDIOGRAM . Ent er year, mont h, and day t he audiomet ric t est is given. (If January 14, 1999, ent er 19990114.)

1 8 . M EETS REFERRAL CRITERIA. Based on t he audiomet ric t est result s, each DoD component should apply it s ow n crit eria.

1 9 . M ILITARY TIM E OF DAY. Ent er f our digit s f or hour of day

(24-hour clock) t his audiogram is complet ed (e.g., " 0830," " 1400," et c.). This f ield is opt ional.

2 0 . HOURS SINCE LAST NOISE EXPOSURE. Ent er appropriat e number of hours prior t o t his audiogram t hat individual w as last exposed t o hazardous noise (e.g., st eady noise 85 dBA or great er and/or impulse noise above 140 dBP).

2 1 . EAR, NOSE, AND THROAT PROBLEM AT TIM E OF TEST. Ent er

"1" (NO) if individual has no ear, nose or t hroat problems at t ime of t est t hat could be causing a t emporary (conduct ive) hearing loss

(e.g., ear canal blocked w it h ear w ax, ear inf ect ion, head cold, et c.). Ent er " 2" (YES) if problem w as present and " 3" (UNKNOWN) if no w ay t o det ermine presence of problem.

2 2 . EXAM INER.

a.Name. Ent er surname, given name and middle init ial of individual operat ing audiomet er.

b.Training Cert if icat ion Number. Ent er audiomet ric t echnician t raining cert if icat ion number.

c.Service Dut y Occupat ion Code. Ent er examiner' s service dut y occupat ion code (see It em 10).

d.Of f ice Symbol. Ent er complet e of f ice symbol w here examiner is perf orming t he t est .

2 3 . AUDIOM ETER.

a.Type. Ent er number f or t ype of audiomet er used (e.g., " 1" f or manual t ype).

b.Model. Ent er manuf act urer' s designat ion.

c.Manuf act urer. Ent er name of company t hat produced audiomet er.

d.Serial Number. Ent er manuf act urer' s serial number.

e.Last Elect roacoust ic Calibrat ion Dat e. Ent er year, mont h and day (see It em 16) of last elect roacoust ic det erminat ion of t his audiomet er' s perf ormance specif icat ions.

2 4 . PERSONAL HEARING PROTECTION.

a.Type Issued. Ent er number f or t ype of hearing prot ect or t hat t he individual w as issued (e.g., " 2" f or t riple f lange, et c.; if " 6 - OTHER," explain in It em 25, " Remarks" ).

b.Size Earplugs. Ent er number f or size of earplugs (single or t riple f lange) used f or each ear (e.g., " 4" f or Large in right ear (R) and " 3" f or Medium or Regular in lef t ear (L)).

c.Double Prot ect ion Used. Ent er " 1" in box if earplugs are not rout inely w orn in combinat ion w it h noise muf f s or a noise-

at t enuat ing helmet . Ent er " 2" if t hey are rout inely w orn t oget her.

d.Glasses Worn. Ent er " 1" in box if eye glasses or goggles are not rout inely w orn w it h noise muf f s or noise-at t enuat ing helmet .

e.Frequency Glasses Worn. Indicat e f requency of use if " 2" w as ent ered in It em 24.d. If " 1" w as ent ered in 24.d., ent er " 3" - N/A.

2 5 . REM ARKS. Print explanat ions f or any of above it ems marked

"OTHER" and any inf ormat ion considered pert inent . Include t he individual' s 8-hour TWA noise exposure, w hen available.

DD FORM 2 2 1 5 (BACK), JAN 2 0 0 0

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audiogram 2215 writing process shown (portion 1)

2. After completing the last section, head on to the subsequent step and enter all required particulars in all these blank fields - NAME, Last First Middle Initial, b TRAINING CERTIFICATION, SERVICE, DUTY, d OFFICE SYM BOL, NUMBER, OCCUPATION CODE, AUDIOM ETER, TYPE MANUAL SELFRECORDING, b M ODEL, M ANUFACTURER, d SERIAL NUM BER, e LAST ELECTROACOUSTIC, and CALIBRATION DATE YYYYMMDD.

Filling in segment 2 in audiogram 2215

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