Document ID: chunk:federal_register_of_legislation:F2016L01332:reg:500:p1
Version: federal_register_of_legislation:F2016L01332
Segment Type: reg
Provision Reference: reg 500 (pt 1/2)
Character Range: 267176–270315

500
  1000
  1500
  2000
  3000
  4000

Accepted percentage hearing loss (APHL): Adjustment for presbyacusis:
          APHL (less adjustment for presbyacusis):

          Accepted hearing impairment:

 * NOTE:
 This form is to be used for assessment of the following types of hearing loss:
      Type 1 (Bilateral mixed hearing loss)
      Type 8 (Bilateral conductive deafness with right sensorineural hearing loss)
      Type 9 (Bilateral conductive deafness with left sensorineural hearing loss)
 and when bone conduction figures are not being used  for types 7, 10 and 11

 *If hearing loss is type 7, 10 or 11, state why bone conduction figures have not been used.

        Accepted hearing loss is equivalent to:

    Date of  Veteran's age at
    audiogram: date of audiogram:

TYPE No *:

    Accepted Hearing Loss (Air Conduction)

  FREQ     Hearing Levels (dB)  Loss
  (Hz)     Right                   Left     (%)
   500
  1000
  1500
  2000
  3000
  4000

          Accepted percentage hearing loss (APHL): Adjustment for presbyacusis:
          APHL (less adjustment for presbyacusis):

          Accepted hearing impairment:

    Total Hearing Loss (Air Conduction)

  FREQ      Hearing Levels (dB)     Loss
  (Hz)     Right                    Left      (%)
   500
  1000
  1500
  2000
  3000
  4000

          Total bilateral hearing loss:
Total hearing impairment: Paired organs policy
    Under the paired organs policy the final hearing impairment is the lesser of twice the
    accepted hearing impairment and the total hearing impairment:

          Final hearing impairment:

    *If bone conduction figures not used for types 12, 13, 14, or 15, state reason:

    Signature  Name (please print)  Date:
                 Accepted hearing loss is equivalent to:  TYPE No :  7

               Bilateral Conductive Deafness

     Date of audiogram:
/ /

     Veteran's age at date of audiogram:

years

 Accepted Hearing Loss

 AIR CONDUCTION BONE CONDUCTION

 FREQ    Hearing Levels   Loss
  (Hz)    Right            Left   (%)
  500
 1000
 1500
 2000
 3000
 4000

 Hearing loss (Air):

A  Hearing loss (Bone): B

      Use formula to calculate loss due to bilateral conductive deafness

     WORKING:

Conductive PLH =

(A - B) x 100
100 - B
               A  =  100   =  100

               B  =  B  =

        A - B   =   100 - B   =  = D (A - B) x 100   =               = C
Conductive hearing loss is C divided by D = (Using formula 7.1) Accepted hearing  impairment:

        Accepted hearing loss is equivalent to:

        Date of audiogram:
    Accepted Hearing Loss

TYPE No :12 / 15

   /  /

    AIR CONDUCTION BONE CONDUCTION

 FREQ    Hearing Levels   Loss
  (Hz)   Right            Left    (%)
  500
 1000
 1500
 2000
 3000
 4000

    Hearing loss (Air):
    Use formula to calculate->

Hearing loss (Bone):

Accepted hearing loss: = E

Conductive PLH =

          A  = B  =
A - B   =
(A - B) x 100   =

          100   = B  =
100 - B   =

(A - B) x 100
100 - B

    = C

    = D

    = E

Accepted hearing impairment: = F

Total Hearing Loss

AIR CONDUCTION

= F

    Paired