Before this form is used, a DD Form 2215, "Reference Audiogram," must already be filed in the individual's health record.
Audiometry: 1 - 90 day, 2 - annual, 3 - termination, 4 - other.
Significant Threshold Shift (STS): enter "1" if no STS is present; enter "2" if STS is present.
STS - YES: the individual must be instructed to stay in a noise free environment (not to exceed 75 dBA or 120 dBP) for at least 14 hours prior to test.
Threshold shift: enter difference between current and most recent reference audiogram for 1000, 2000, 3000 and 4000 Hz.
Remarks: print any information considered pertinent; include the individual's 8-hour TWA noise exposure, when available.
Results: entered in 5 dB increments; if responses exceed maximum limits of audiometer, enter that limit with plus sign.
| Question | Answer |
|---|---|
| Form Name | DD Form 2216 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 153 |
| Avg. time to fill out | 26 min |
| Edition | FEB 2025 |
| Previous edition | May be used |
| Privacy Act | This form is subject to the Privacy Act of 1974 - use Blanket PAS - DD Form 2005 |
| Other names | DD Form 2216, DD 2216, DD2216, DD-2216, Hearing Conservation Data |
| Official source | DD Form 2216 (Rev FEB 2025), Department of Defense |
Dd Form 2216 isn’t the one you’re looking for?