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.
