Dd Form 2217 – Fill Out and Use This PDF

a.MANUFACTURER

b. MODEL

c. SERIAL NUMBER

d. LAST ELECTROACOUSTIC CALIBRATION

DATE (YYYYMMDD)

a. NAME (Last, First, Middle Initial)

b. FACILITY

c. LOCATION

DD FORM 2217, JAN 2000

PREVIOUS EDITION MAY BE USED.

Adobe Professional 7.0

PURPOSE: This f orm is used t o record biological/ elect roacoust ic monit or checks of t he calibrat ion of one audiomet er. Hearing t hreshold levels of one person t est ed on t his audiomet er are recorded as

w ell as not at ions of any signal dist ort ions and noise t ransient s.

GENERAL: Print all inf ormat ion in ink. Biological audiomet er calibrat ion checks w ill be perf ormed every day t he audiomet er is used. More f requent int ervals (e.g., daily checks) may be required by t he DoD component . St art a new f orm if a dif f erent list ener is used and/or af t er t he audiomet er is re-calibrat ed.

1. AUDIOMETER.

a.Manufacturer. Ent er name of company t hat produced audiomet er.

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

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

d.Last Electroacoustic Calibration Date. Ent er year, mont h, and day of last elect roacoust ic det erminat ion of t his audiomet er' s perf ormance specif icat ions. If January 31, 2000, ent er 2000131 .

2. LISTENER.

a.Name. Ent er surname, given name and middle init ial of individual being t est ed, i.e., t he person list ening t hrough earphones of audiomet er.

b.Facility. Ent er name of inst allat ion (e.g., Fort Bliss).

c.Location. Ent er st at e or APO (e.g., TX, et c.).

3. DATES AND DATA REVIEW.

a.Date. Ent er year, mont h, and day (see It em 1 .d.) of each biological calibrat ion check.

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

3. DATES AND DATA REVIEW (Continued)

c.Calibration Check.

(1)Pass: + 5 dB of Baseline at 500 - 4000 Hert z (Hz) and + 10 dB at 6000 Hz. Mark (X) t his column if periodic biological calibrat ion check is

w it hin + 5 dB of baseline at 500 - 4000 Hz and + 10 dB at 6000 Hz (e.g., if baseline of 15 dB has been est ablished at 1000 Hz in right ear, any of t he f ollow ing hearing t hreshold levels obt ained on periodic check w ould require no act ion: 10, 15, or 20 dB).

(2)Fail: Great er Than + 5 dB of Baseline at

500 - 4000 Hz and + 10 dB at 6000 Hz. Mark

t his column if periodic biological calibrat ion check is great er t han + 5 dB of baseline at 500 - 4000 Hz and + 10 dB at 6000 Hz (e.g., if baseline of 15 dB has been est ablished at 1000 Hz in right ear, any

t hreshold levels of 5 dB or less or 25 dB or great er w ould require act ion). This discrepancy must be account ed f or or audiomet er should receive an elect roacoust ic calibrat ion. Ref er t o DoD component inst ruct ions f or f urt her guidance.

4. HEARING THRESHOLD LEVELS OF TEST FREQUENCIES.

a.Baseline. Af t er list ener has demonst rat ed

t est -ret est reliabilit y (i.e., if t est result s of several pre-t est s are consist ent ly w it hin + 5 dB of each ot her), ent er hearing t hreshold levels of last t est result s in increment s of 5 dB (e.g., 0, 5, 10, 15, et c.).

b.Periodic Biological Calibration Checks. Ent er hearing t hreshold levels in increment s of 5 dB. Use a separat e line f or each calibrat ion check.

5. REMARKS. Ent er any comment s pert aining t o signal dist ort ion or noise t ransient s including dat e of check. Include addit ional inf ormat ion on locat ion of t he audiomet er (e.g., building number and room number) and t he t ype of acoust ic t est environment (e.g., single-w alled, single-person audiomet ric examinat ion boot h, et c.).