Document ID: chunk:federal_register_of_legislation:F2016L01332:reg:500
Version: federal_register_of_legislation:F2016L01332
Segment Type: reg
Provision Reference: reg 500
Character Range: 266477–267176

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Accepted hearing loss: Correction for presbyacusis:
           Accepted hearing loss (less age correction):

           Accepted hearing impairment:

=  A

=  B

=  A - B

    NOTE:
This form is to be used for assessment of Type 4 hearing loss (Bilateral sensorineural deafness)
    *If bone conduction figures have not been used, state reason:

    Signature  Name (please print)  Date

/ /

Accepted hearing loss is equivalent to: Date of audiogram:
     Veteran's age at date of audiogram:

 Accepted Hearing Loss (Air Conduction)

 TYPE No *:

/  /

      years

  FREQ    Hearing Levels (dB)     Loss
  (Hz)    Right                Left     (%)