Dd Form 2216 – Fill Out and Use This PDF

HEARING CONSERVATION DATA

(This form is subject to the Privacy Act of 1974 - use Blanket PAS - DD Form 2005)

1. ZIP CODE/APO/FPO/PAS

2. DOD COMPONENT
	A - ARMY	F - AIR FORCE	1 - OTHER DOD
	N - NAVY	M - MARINE CORPS	ACTIVITY

3. SERVICE COMPONENT
	R - REGULAR	G - NATIONAL GUARD
	V - RESERVE	1 - OTHER

12. LOCATION - PLACE OF WORK

13. MAJOR COMMAND

14. DUTY TELEPHONE (Include area code)

DD FORM 2216, JAN 2000

PREVIOUS EDITION MAY BE USED.

Adobe Professional 7.0

PURPOSE: This f orm is used t o record t he result s of periodic and f ollow up audiomet ry f or individuals rout inely exposed t o hazardous noise. Bef ore t his f orm is used, a DD Form 2215, " Ref erence Audiogram," must already be f iled in t he individual' s healt h record.

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 COMPONENT. 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 COMPONENT. Enter letter in box corresponding to 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 -time status). Enter " 1" for all others not listed.

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

5. NAME. Ent er surname, given name and middle init ial of individual being t est ed.

6. DATE OF BIRTH. Enter year, month, day.

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

8. PAY GRADE, UNIFORMED 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/Lieutenant 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 Master Sergeant/Master Chief Petty Officer

E08 - Master Sergeant (A,M)/Senior Chief Petty Officer/Senior Master Sergeant/First Sergeant(A)

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

Master Sergeant (F)/Platoon Sergeant (A)/Specialist -7

E06 - Staff Sergeant/Technical Sergeant/Petty Officer First Class/ Specialist -6

E05 - Sergeant (A,M)/Staff Sergeant/Petty Officer Second Class/ Specialist -5

E04 - Corporal/Sergeant (F)/Petty Officer 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 - Private (PV2)/Private (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 national, contractor, etc.).

10. 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 actually w orking (e.g., for a carpenter enter " 4607" ).

11. MAILING ADDRESS OF ASSIGNMENT. 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 .

12. 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.

13. MAJOR COMMAND. Ent er aut horized abbreviat ion of milit ary major command t o w hich individual is assigned.

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

15. AUDIOMETRY.

a.Purpose. Ent er number in box f or reason t o complet e audiogram.

"1" - First periodic t est given 90 days af t er beginning dut ies in noise- hazardous area or operat ion; " 2" - Periodic t est given at yearly int ervals; " 3" - Last t est given, regardless of noise exposure hist ory, bef ore t erminat ion of act ive dut y or employment ; " 4" - Test at int erval f or reason not list ed above.

b.Current Audiogram Date. Enter year, month, day (e.g., if January 31, 2000, enter 20000131) that audiometric test is given and current threshold levels

det ermined f or t his individual at six f requencies in each ear. Result s are ent ered in 5 dB 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+ ).

15.c. Reference Audiogram Date. Ent er year, mont h, and day ref erence

t est result s w ere obt ained. See DD Form 2215, " Ref erence Audiogram," or other appropriate source. Enter threshold levels in 5 dB increments from reference audiogram.

d.Significant Threshold Shift (STS). Ent er " 1" if no STS is present ; ent er

"2' if STS is present .

STS - NO: See DoD component specif ic manuals f or det ailed guidance.

STS-YES: Out lines procedures required w hen a signif icant t hreshold shif t present : " Not if y Supervisor" - Not if y individual' s supervisor t hat signif icant t hreshold shif t has been f ound and f ollow up audiogram must be done. " Follow up No. 1 Af t er Minimum 14 Hours Noise Free" - Schedule individual f or f irst f ollow up audiogram. They must be inst ruct ed t o st ay in a noise f ree environment (not t o exceed 75 dBA or 120 dBP) f or at least 14 hours prior t o t est . They must be t old t o avoid environment s in w hich noise levels make it necessary t o use raised voice t o t alk at 1 met er (3 f eet )

dist ance. If examinee has obvious ear problem (e.g., earache, draining ear, excessive cerumen buildup), he/she should be examined by physician and f ollow up post poned unt il af t er any necessary t reat ment .

e.Threshold Shift. Ent er dif f erence bet w een current and most recent reference audiogram for 1000, 2000, 3000 and 4000 Hz. Refer to DoD component manuals f or est ablished crit eria. Ent er " + " t o indicat e posit ive shif t (poorer hearing) or " -" t o indicat e negat ive shif t (bet t er hearing) on current audiogram.

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

g.Type of Personal Hearing Protection Used. Enter number for type of hearing prot ect ion t hat is rout inely used by individual.

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

i.Training Certificate Number. Ent er audiomet ric t echnician t raining certificate number.

j.Service Duty Occupation Code. Ent er examiner' s service dut y occupat ion code (see It em 10).

k.Office Symbol. Ent er complet e of f ice symbol w here examiner is

perf orming t he t est .

l.Audiometer Type. Enter number for type of audiometer used (e.g., " 1" for manual type, etc.).

m.Model. Enter manufacturer' s designation of audiometer.

n.Manufacturer. Enter name of company that produced audiometer.

o.Serial Number. Enter manufacturer' s serial number of audiometer.

p.Last Electroacoustic Calibration Date. Ent er year, mont h and day (see It em 15.b.) of last elect roacoust ic det erminat ion of t his audiomet er' s

perf ormance specif icat ions.

16. FOLLOWUP NO. 1. If signif icant t hreshold shif t det ermined on periodic t est , record result s of f irst f ollow up audiogram in t his sect ion. Mark (X) box t o cert if y " Minimum 14 Hours Noise Free Since Current Audiogram (see It em 15.b.)" .

b., c., and e., " Current Audiogram," " Ref erence Audiogram," and

" Threshold Shif t " complet ed in same f ormat as above. Not e: Hearing

t hreshold levels ent ered in 16.c. are t he same values as t hose used in 15.c.

d." STS - NO" - If no STS not ed, ent er " 1" in box and f ollow st eps in " STS

-NO" sect ion.

"STS - YES" - If STS remains f ollow ing t his examinat ion (Follow up No. 1), follow service component instructions (e.g., supervisor is notified for the second t ime, individual is scheduled f or Follow up No. 2 audiogram, and individual is inst ruct ed t o st ay in a noise f ree environment (not t o exceed 75 dBA or 120 dBP) f or a minimum of 14 hours of audit ory rest since current audiogram (Item 15.b.)).

e.through m. Ent er t he required inf ormat ion according t o guidelines f or ent ries on periodic audiogram.

17. FOLLOWUP NO. 2. If signif icant t hreshold shif t det ermined on Follow up No. 1, record result s of Follow up No. 2 in t his sect ion. Mark (X) box t o cert if y " Minimum 14 Hours Noise Free Since Current Audiogram (see Item 15.b.)" .

b., c., and e., " Current Audiogram," " Ref erence Audiogram," and

" Threshold Shif t " complet ed in same f ormat as above. Not e: Hearing

t hreshold levels ent ered in 17.c. are t he same values as t hose used in 15.c.

d." STS - NO" - If no STS not ed, ent er " 1" in box and f ollow st eps in " STS

-NO" sect ion.

"STS - YES" - If STS remains f ollow ing t his examinat ion (Follow up No. 2), enter " 2" in box. Refer to DoD component instructions for appropriate pat ient disposit ion.

e.through m. Ent er t he required inf ormat ion according t o guidelines f or ent ries on periodic audiogram.

See specif ic DoD component manuals regarding f ollow up procedures required in addit ion t o t hose list ed above. For example, if t he annual t est indicat es a " negat ive" t hreshold shif t and is conf irmed on t he f irst f ollow up, t he ref erence audiogram may be reest ablished at t his t ime w it hout any further follow up testing for DA personnel.