<table>
<tbody>
<tr class="odd">
<td><p><strong>REFERENCE AUDIOGRAM</strong></p></td>
<td><h3>ZIP CODE/APO</h3></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h3>DOD COMPONENT</h3></td>
<td><h3>A-ARMY M-MARINES</h3>
<p><strong>N-NAVY I-OTHER DOD ACTIVITY</strong></p>
<p><strong>F-AIR FORCE</strong></p></td>
<td><h3>SERVICE COMPONENT</h3></td>
<td><h3>R-REGULAR G-NATIONAL GUARD</h3>
<p><strong>V-RESERVE I-OTHER</strong></p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="even">
<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
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</tr>
<tr class="odd">
<td><h1>PERSONAL DATA</h1></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<tr class="even">
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<td></td>
<td></td>
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<td></td>
</tr>
<tr class="odd">
<td><h3>SSN</h3></td>
<td><h3>LAST NAME-FIRST NAME-MIDDLE INITIAL</h3></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h3>SEX</h3></td>
<td><h3>M-MALE</h3>
<p><strong>F-FEMALE</strong></p></td>
<td><h3><strong>DATE OF BIRTH </strong><em>(yyyy-mm-dd)</em></h3></td>
<td><h4>PAY GRADE, UNIFORMED</h4>
<p><strong>SERVICES</strong></p></td>
<td><h4>GRADE, CIVILIAN</h4></td>
<td><h4>SERVICE DUTY</h4>
<p><strong>OCCUPATIONAL CODE</strong></p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
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<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h4>MAILING ADDRESS OF ASSIGNMENT</h4></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="even">
<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h4>LOCATION – PLACE OF WORK</h4></td>
<td><h4>MAJOR COMMAND</h4></td>
<td><h4>DUTY PHONE</h4></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
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</tr>
<tr class="even">
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h1>AUDIOMETRY</h1></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="even">
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h4></h4></td>
<td><h4>1. REFERENCE ESTABLISHED PRIOR TO INITIAL DUTY IN HAZARDOUS
NOISE AREAS</h4>
<h4>2. REFERENCE ESTABLISHED FOLLOWING EXPOSURE IN NOISE DUTIES</h4>
<h4>3. REFERENCE RE-ESTABLISHED AFTER FOLLOWUP PROGRAM</h4></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<tr class="even">
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<td></td>
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</tr>
<tr class="odd">
<td><h5>HEARING THRESHOLD LEVELS OF TEST FREQUENCIES RE: ANSI
S3.6</h5></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="odd">
<td></td>
<td><h1>LEFT EAR</h1></td>
<td><h1>RIGHT EAR</h1></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
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<td></td>
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</tr>
<tr class="odd">
<td></td>
<td><p>500</p></td>
<td><p>1000</p></td>
<td><p>2000</p></td>
<td><p>3000</p></td>
<td><p>4000</p></td>
<td><p>6000</p></td>
<td><p>500</p></td>
<td><p>1000</p></td>
<td><p>2000</p></td>
<td><p>3000</p></td>
<td><p>4000</p></td>
<td><p>6000</p></td>
<td></td>
</tr>
<tr class="even">
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<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
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<tr class="even">
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>DATE OF AUDIOGRAM <em>(yyyymmdd)</em></p></td>
<td><p>DAY OF WEEK</p></td>
<td><h4>MIL-TIME-DAY</h4></td>
<td><h4>HOURS SINCE</h4>
<p><strong>LAST NOISE EXPOSURE</strong></p></td>
<td><h4>ENT PROBLEM AT TIME OF TEST</h4></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="even">
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<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="odd">
<td></td>
<td><h3></h3></td>
<td><p><strong> 1-SUN 4-WED 7-SAT</strong></p>
<p>2-MON 5-THURS</p>
<p>3-TUES 6-FRI</p></td>
<td></td>
<td></td>
<td><h4></h4></td>
<td><h4>1- NO 2-YES</h4>
<p><strong> 3-UNKNOWN</strong></p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="even">
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<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h1>EXAMINER</h1></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h4>LAST NAME-FIRST NAME-MIDDLE INITIAL</h4></td>
<td><h4>TRAINING</h4>
<p><strong>CERT.NO.</strong></p></td>
<td><h4>SSN</h4></td>
<td><h4>SERVICE DUTY</h4>
<p><strong>OCCUPATIONAL CODE</strong></p></td>
<td><h4>OFFICE SYMBOL</h4></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
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<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>AUDIOMETER</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
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<tr class="even">
<td></td>
<td></td>
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<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>TYPE</p></td>
<td><p>1-MANUAL</p>
<p>2-SELF RECORDING</p>
<p>(automatic)</p>
<p>3-MICROPROCESSOR</p></td>
<td><h4>MODEL</h4></td>
<td><h4>MANUFACTURER</h4></td>
<td><h4>SERIAL NUMBER</h4></td>
<td><h4>LAST ELECTROACOUSTIC CALIB</h4>
<p><strong>DATE </strong><em>(yyyy-mm-dd)</em></p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
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<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>PERSONAL HEARING PROTECTION</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
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</tr>
<tr class="even">
<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>TYPE USED</p></td>
<td></td>
<td><p>EARPLUGS ISSUED</p></td>
<td><p>SIZE EARPLUGS</p></td>
<td><p>DOUBLE PRO-</p>
<p>TECTION USED</p></td>
<td><p>GLASSES WORN</p>
<p><em>(including goggles)</em></p></td>
<td><p>FREQUENCY</p>
<p>GLASSES WORN</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td><p>1-SINGLE FLANGE (V51R) 5-NOISE MUFFS</p>
<p>2- TRIPLE FLANGE 6-OTHER</p>
<p>3-HAND FORMED EARPLUGS</p>
<p>4-EAR CANAL CAPS</p></td>
<td></td>
<td><p>1-N0 2-YES</p>
<p>3-PREVIOUSLY</p>
<p>ISSUED</p></td>
<td><p>R</p></td>
<td><p>L</p></td>
<td><p>1-XS</p>
<p>2-S</p>
<p>3-M</p>
<p>4-L</p>
<p>5-XL</p></td>
<td></td>
<td><p>1-NO</p>
<p>2-YES</p></td>
<td></td>
<td><p>1-NO</p>
<p>2-YES</p></td>
<td></td>
<td><p>1-ALWAYS</p>
<p>2-SELDOM</p>
<p>3-N/A</p></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
<td></td>
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</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h4>REMARKS</h4></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
<tr class="even">
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h1>CONTENTS REVIEWED AND VALIDATED BY</h1></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
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</tr>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>NAME OF REVIEWER <em>(Signature)</em></p></td>
<td><h4>SERVICE DUTY</h4>
<p><strong>OCCUPATION CODE</strong></p></td>
<td><h4>AUTOVON</h4></td>
<td><h4>SSN</h4></td>
<td><h4>OFFICE SYMBOL</h4></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</tr>
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<td></td>
</tr>
</tbody>
</table>

DD FORM 2215, 1 SEP 79 USAPPC V1.00