DD Form 2216 Hearing Conservation Data

DD Form 2216 - also known as the "Hearing Conservation Data" - is a Military form issued and used by the United States Department of Defense.

The form - often incorrectly referred to as the DA form 2216 - was last revised on January 1, 2000. Download an up-to-date fillable DD Form 2216 down below in PDF-format or find it on the Department of Defense documentation website.

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HEARING CONSERVATION DATA
1. ZIP CODE/APO/FPO/PAS
(This form is subject to the Privacy Act of 1974 - use Blanket PAS - DD Form 2005)
2. DOD COMPONENT
3. SERVICE COMPONENT
A - ARMY
F - AIR FORCE
1 - OTHER DOD
R - REGULAR
G - NATIONAL GUARD
N - NAVY
M - MARINE CORPS
ACTIVITY
V - RESERVE
1 - OTHER
7. SEX
4. SOCIAL SECURITY NUMBER
5. NAME (Last, First, Middle Initial)
6. DATE OF BIRTH
M - MALE
(YYYYMMDD)
F - FEMALE
8. PAY GRADE,
9. PAY GRADE,
10. SERVICE DUTY
11. MAILING ADDRESS OF ASSIGNMENT
UNIFORMED SERVICES
CIVILIAN
OCCUPATION CODE
12. LOCATION - PLACE OF WORK
13. MAJOR COMMAND
14. DUTY TELEPHONE (Include area code)
15. AUDIOMETRY
a.
PURPOSE
1 - 90 DAY
2 - ANNUAL
3 - TERMINATION
4 - OTHER
LEFT
RIGHT
AUDIOMETRIC DATA
RE: ANSI S3.6 - 1989
500
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
b. CURRENT AUDIOGRAM DATE
(YYYYMMDD)
c.
REFERENCE AUDIOGRAM
DATE
(YYYYMMDD)
d. SIGNIFICANT THRESHOLD SHIFT
e. THRESHOLD
SHIFT
(STS)
1 - NO
2 - YES
f. REMARKS (Include exposure data)
g. TYPE OF PERSONAL HEARING PROTECTION USED
1 - SINGLE FLANGE (VS1R)
2 - TRIPLE FLANGE
3 - HAND FORMED EARPLUGS
4 - EAR CANAL CAPS
5- NOISE MUFFS
6 - OTHER
h. EXAMINER NAME (Last, First, Middle Initial)
k.
OFFICE
SYMBOL
i. TRAINING CERTIFICATE NO.
j. SERVICE DUTY OCCUPATION
CODE
l.
AUDIOMETER
TYPE
m. MODEL
n. MANUFACTURER
o. SERIAL NUMBER
p. LAST ELECTROACOUSTIC
CALIBRATION DATE
1 - MANUAL
(YYYYMMDD)
2 - SELF-RECORDING (Automatic)
3 - MICROPROCESSOR
16. FOLLOWUP NO. 1
a.
MINIMUM
14 HOURS NOISE FREE SINCE CURRENT AUDIOGRAM (See item 15.b.)
LEFT
RIGHT
AUDIOMETRIC DATA
RE: ANSI S3.6 - 1989
500
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
b. CURRENT AUDIOGRAM DATE
(YYYYMMDD)
c.
REFERENCE AUDIOGRAM
DATE
(YYYYMMDD)
d. SIGNIFICANT THRESHOLD SHIFT
e. THRESHOLD
SHIFT
(STS)
1 - NO
2 - YES
f. EXAMINER NAME (Last, First, Middle Initial)
i.
OFFICE
SYMBOL
g. TRAINING CERTIFICATE NO.
h. SERVICE DUTY OCCUPATION
CODE
j.
AUDIOMETER
TYPE
k.
MODEL
l.
MANUFACTURER
m. SERIAL NUMBER
n. LAST ELECTROACOUSTIC
CALIBRATION DATE
1 - MANUAL
(YYYYMMDD)
2 - SELF-RECORDING (Automatic)
3 - MICROPROCESSOR
17. FOLLOWUP NO. 2
a.
MINIMUM
14 HOURS NOISE FREE SINCE CURRENT AUDIOGRAM (See item 15.b.)
LEFT
RIGHT
AUDIOMETRIC DATA
RE: ANSI S3.6 - 1989
500
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
b. CURRENT AUDIOGRAM DATE
(YYYYMMDD)
c.
REFERENCE AUDIOGRAM
DATE
(YYYYMMDD)
d. SIGNIFICANT THRESHOLD SHIFT
e. THRESHOLD
SHIFT
(STS)
1 - NO
2 - YES
f. EXAMINER NAME (Last, First, Middle Initial)
i.
OFFICE
SYMBOL
g. TRAINING CERTIFICATE NO.
h. SERVICE DUTY OCCUPATION
CODE
j.
AUDIOMETER
TYPE
k.
MODEL
l.
MANUFACTURER
m. SERIAL NUMBER
n. LAST ELECTROACOUSTIC
CALIBRATION DATE
1 - MANUAL
(YYYYMMDD)
2 - SELF-RECORDING (Automatic)
3 - MICROPROCESSOR
DD FORM 2216, JAN 2000
PREVIOUS EDITION MAY BE USED.
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HEARING CONSERVATION DATA
1. ZIP CODE/APO/FPO/PAS
(This form is subject to the Privacy Act of 1974 - use Blanket PAS - DD Form 2005)
2. DOD COMPONENT
3. SERVICE COMPONENT
A - ARMY
F - AIR FORCE
1 - OTHER DOD
R - REGULAR
G - NATIONAL GUARD
N - NAVY
M - MARINE CORPS
ACTIVITY
V - RESERVE
1 - OTHER
7. SEX
4. SOCIAL SECURITY NUMBER
5. NAME (Last, First, Middle Initial)
6. DATE OF BIRTH
M - MALE
(YYYYMMDD)
F - FEMALE
8. PAY GRADE,
9. PAY GRADE,
10. SERVICE DUTY
11. MAILING ADDRESS OF ASSIGNMENT
UNIFORMED SERVICES
CIVILIAN
OCCUPATION CODE
12. LOCATION - PLACE OF WORK
13. MAJOR COMMAND
14. DUTY TELEPHONE (Include area code)
15. AUDIOMETRY
a.
PURPOSE
1 - 90 DAY
2 - ANNUAL
3 - TERMINATION
4 - OTHER
LEFT
RIGHT
AUDIOMETRIC DATA
RE: ANSI S3.6 - 1989
500
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
b. CURRENT AUDIOGRAM DATE
(YYYYMMDD)
c.
REFERENCE AUDIOGRAM
DATE
(YYYYMMDD)
d. SIGNIFICANT THRESHOLD SHIFT
e. THRESHOLD
SHIFT
(STS)
1 - NO
2 - YES
f. REMARKS (Include exposure data)
g. TYPE OF PERSONAL HEARING PROTECTION USED
1 - SINGLE FLANGE (VS1R)
2 - TRIPLE FLANGE
3 - HAND FORMED EARPLUGS
4 - EAR CANAL CAPS
5- NOISE MUFFS
6 - OTHER
h. EXAMINER NAME (Last, First, Middle Initial)
k.
OFFICE
SYMBOL
i. TRAINING CERTIFICATE NO.
j. SERVICE DUTY OCCUPATION
CODE
l.
AUDIOMETER
TYPE
m. MODEL
n. MANUFACTURER
o. SERIAL NUMBER
p. LAST ELECTROACOUSTIC
CALIBRATION DATE
1 - MANUAL
(YYYYMMDD)
2 - SELF-RECORDING (Automatic)
3 - MICROPROCESSOR
16. FOLLOWUP NO. 1
a.
MINIMUM
14 HOURS NOISE FREE SINCE CURRENT AUDIOGRAM (See item 15.b.)
LEFT
RIGHT
AUDIOMETRIC DATA
RE: ANSI S3.6 - 1989
500
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
b. CURRENT AUDIOGRAM DATE
(YYYYMMDD)
c.
REFERENCE AUDIOGRAM
DATE
(YYYYMMDD)
d. SIGNIFICANT THRESHOLD SHIFT
e. THRESHOLD
SHIFT
(STS)
1 - NO
2 - YES
f. EXAMINER NAME (Last, First, Middle Initial)
i.
OFFICE
SYMBOL
g. TRAINING CERTIFICATE NO.
h. SERVICE DUTY OCCUPATION
CODE
j.
AUDIOMETER
TYPE
k.
MODEL
l.
MANUFACTURER
m. SERIAL NUMBER
n. LAST ELECTROACOUSTIC
CALIBRATION DATE
1 - MANUAL
(YYYYMMDD)
2 - SELF-RECORDING (Automatic)
3 - MICROPROCESSOR
17. FOLLOWUP NO. 2
a.
MINIMUM
14 HOURS NOISE FREE SINCE CURRENT AUDIOGRAM (See item 15.b.)
LEFT
RIGHT
AUDIOMETRIC DATA
RE: ANSI S3.6 - 1989
500
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
b. CURRENT AUDIOGRAM DATE
(YYYYMMDD)
c.
REFERENCE AUDIOGRAM
DATE
(YYYYMMDD)
d. SIGNIFICANT THRESHOLD SHIFT
e. THRESHOLD
SHIFT
(STS)
1 - NO
2 - YES
f. EXAMINER NAME (Last, First, Middle Initial)
i.
OFFICE
SYMBOL
g. TRAINING CERTIFICATE NO.
h. SERVICE DUTY OCCUPATION
CODE
j.
AUDIOMETER
TYPE
k.
MODEL
l.
MANUFACTURER
m. SERIAL NUMBER
n. LAST ELECTROACOUSTIC
CALIBRATION DATE
1 - MANUAL
(YYYYMMDD)
2 - SELF-RECORDING (Automatic)
3 - MICROPROCESSOR
DD FORM 2216, JAN 2000
PREVIOUS EDITION MAY BE USED.
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Adobe Professional 7.0
INSTRUCTIONS
(Refer to DoD Component Instructions for additional guidance)
PURPOSE: This form is used to record the results of periodic and followup
15.c. Reference Audiogram Date. Enter year, month, and day reference
audiometry for individuals routinely exposed to hazardous noise. Before this form
test results were obtained. See DD Form 2215, "Reference Audiogram," or
is used, a DD Form 2215, "Reference Audiogram," must already be filed in the
other appropriate source. Enter threshold levels in 5 dB increments from
individual's health record.
reference audiogram.
d. Significant Threshold Shift (STS). Enter "1" if no STS is present; enter
1. ZIP CODE/APO/FPO/PAS. Enter nine digit ZIP Code/APO/FPO/ PAS of where
"2' if STS is present.
audiometric test is conducted.
STS - NO: See DoD component specific manuals for detailed guidance.
2. DOD COMPONENT. Enter letter in box of major organizational subdivision of
STS-YES: Outlines procedures required when a significant threshold
DoD to which military or civilian individual is assigned. Enter "1" if DoD
shift present: "Notify Supervisor" - Notify individual's supervisor that
component is not listed.
significant threshold shift has been found and followup audiogram must be
done. "Followup No. 1 After Minimum 14 Hours Noise Free" - Schedule
3. SERVICE COMPONENT. Enter letter in box corresponding to primary
individual for first followup audiogram. They must be instructed to stay in a
subdivision of separate military service in which military is assigned (e.g., Regular
(R) - standing military component of armed forces in peace and war; Reserve (V) -
noise free environment (not to exceed 75 dBA or 120 dBP) for at least 14
component of ready trained personnel for military service when needed, etc.;
hours prior to test. They must be told to avoid environments in which noise
National Guard (G) - component of National Guard personnel in full-time or
levels make it necessary to use raised voice to talk at 1 meter (3 feet)
part-time status). Enter "1" for all others not listed.
distance. If examinee has obvious ear problem (e.g., earache, draining ear,
excessive cerumen buildup), he/she should be examined by physician and
4. SOCIAL SECURITY NUMBER. Enter nine digit social security number. If foreign
followup postponed until after any necessary treatment.
national, enter "FN" in middle two blocks.
e. Threshold Shift. Enter difference between current and most recent
5. NAME. Enter surname, given name and middle initial of individual being tested.
reference audiogram for 1000, 2000, 3000 and 4000 Hz. Refer to DoD
component manuals for established criteria. Enter "+" to indicate positive
6. DATE OF BIRTH. Enter year, month, day.
shift (poorer hearing) or "-" to indicate negative shift (better hearing) on
current audiogram.
7. SEX. Enter "M" if male, "F" if female.
f. Remarks. Print any information considered pertinent. Include the
individual's 8-hour TWA noise exposure, when available.
8. PAY GRADE, UNIFORMED SERVICES. For military personnel only, enter
military personnel class and pay level serial number as follows:
g. Type of Personal Hearing Protection Used. Enter number for type of
O11 - General of the Army/General of the Air Force/Fleet Admiral
hearing protection that is routinely used by individual.
O10 - General/Admiral
h. Examiner Name. Enter surname, given name and middle initial of
O09 - Lieutenant General/Vice Admiral
individual operating audiometer.
O08 - Major General/Rear Admiral (Upper Half)
i. Training Certificate Number. Enter audiometric technician training
O07 - Brigadier General/Rear Admiral (Lower Half)/Commodore
certificate number.
O06 - Colonel (A,F,M)/Captain (N)
j. Service Duty Occupation Code. Enter examiner's service duty
O05 - Lieutenant Colonel/Commander
O04 - Major/Lieutenant Commander
occupation code (see Item 10).
O03 - Captain (A,F,M)/Lieutenant (N)
k. Office Symbol. Enter complete office symbol where examiner is
O02 - First Lieutenant/Lieutenant Junior Grade
performing the test.
O01 - Second Lieutenant/Ensign
l. Audiometer Type. Enter number for type of audiometer used (e.g., "1"
W05 - Chief Warrant Officer, W-5
for manual type, etc.).
W04 - Chief Warrant Officer, W-4
m. Model. Enter manufacturer's designation of audiometer.
W03 - Chief Warrant Officer, W-3
W02 - Chief Warrant Officer, W-2
n. Manufacturer. Enter name of company that produced audiometer.
W01 - Warrant Officer, W-1
o. Serial Number. Enter manufacturer's serial number of audiometer.
C00 - Cadet/Midshipman
p. Last Electroacoustic Calibration Date. Enter year, month and day (see
E09 - Sergeant Major/Chief Master Sergeant/Master Chief Petty Officer
Item 15.b.) of last electroacoustic determination of this audiometer's
E08 - Master Sergeant (A,M)/Senior Chief Petty Officer/Senior
performance specifications.
Master Sergeant/First Sergeant(A)
E07 - Sergeant First Class/Gunnery Sergeant/Chief Petty Officer/
Master Sergeant (F)/Platoon Sergeant (A)/Specialist-7
16. FOLLOWUP NO. 1. If significant threshold shift determined on periodic
E06 - Staff Sergeant/Technical Sergeant/Petty Officer First Class/
test, record results of first followup audiogram in this section. Mark (X) box
Specialist-6
to certify "Minimum 14 Hours Noise Free Since Current Audiogram (see Item
E05 - Sergeant (A,M)/Staff Sergeant/Petty Officer Second Class/
15.b.)".
Specialist-5
b., c., and e., "Current Audiogram," "Reference Audiogram," and
E04 - Corporal/Sergeant (F)/Petty Officer Third Class/Specialist-4
"Threshold Shift" completed in same format as above. Note: Hearing
E03 - Private First Class (A)/Airman First Class/Lance Corporal/Seaman
threshold levels entered in 16.c. are the same values as those used in 15.c.
E02 - Private (PV1)/Airman/Private First Class (M)/Seaman Apprentice
E01 - Private (PV2)/Private (M)/Airman Basic/Seaman Recruit
d. "STS - NO" - If no STS noted, enter "1" in box and follow steps in "STS
- NO" section.
9. GRADE, CIVILIAN. Enter two letters and two numbers of Federal civilian
"STS - YES" - If STS remains following this examination (Followup No.
employee rank (e.g., WG05, GS11, etc). Letter entries will be WG, WL, WS, WN,
1), follow service component instructions (e.g., supervisor is notified for the
WD or GS. Number entries will be 01 to 18. Enter "1111" if other (e.g., foreign
second time, individual is scheduled for Followup No. 2 audiogram, and
national, contractor, etc.).
individual is instructed to stay in a noise free environment (not to exceed 75
dBA or 120 dBP) for a minimum of 14 hours of auditory rest since current
10. SERVICE DUTY OCCUPATION CODE. Enter code to which military member's
duty occupation is assigned (e.g., MOS, SSI, NEC/Rating, NOBC or AFSC in which
audiogram (Item 15.b.)).
individual is actually working). Enter number code of civilian job series in which
e. through m. Enter the required information according to guidelines for
civilian member is actually working (e.g., for a carpenter enter "4607").
entries on periodic audiogram.
11. MAILING ADDRESS OF ASSIGNMENT. Enter installation name (and street
17. FOLLOWUP NO. 2. If significant threshold shift determined on
address for Navy and Marines), unit, office symbol, and ZIP Code/APO/ FPO/PAS of
Followup No. 1, record results of Followup No. 2 in this section. Mark (X)
individual's current duty assignment.
box to certify "Minimum 14 Hours Noise Free Since Current Audiogram (see
12. LOCATION - PLACE OF WORK. Enter specific location where individual is
Item 15.b.)".
routinely exposed to hazardous noise including building number (e.g., Corpus
b., c., and e., "Current Audiogram," "Reference Audiogram," and
Christi, NAS, Building 1571, Carpenter Shop). For Air Force personnel, enter
"Threshold Shift" completed in same format as above. Note: Hearing
12-digit Workplace Identifier Code per AFOSH Std. 161-17.
threshold levels entered in 17.c. are the same values as those used in 15.c.
d. "STS - NO" - If no STS noted, enter "1" in box and follow steps in "STS
13. MAJOR COMMAND. Enter authorized abbreviation of military major command
to which individual is assigned.
- NO" section.
"STS - YES" - If STS remains following this examination (Followup No.
14. DUTY TELEPHONE. Enter individual's duty telephone number.
2), enter "2" in box. Refer to DoD component instructions for appropriate
patient disposition.
15. AUDIOMETRY.
e. through m. Enter the required information according to guidelines for
a. Purpose. Enter number in box for reason to complete audiogram.
entries on periodic audiogram.
"1" - First periodic test given 90 days after beginning duties in noise- hazardous
area or operation; "2" - Periodic test given at yearly intervals; "3" - Last test given,
regardless of noise exposure history, before termination of active duty or
See specific DoD component manuals regarding followup procedures
employment; "4" - Test at interval for reason not listed above.
required in addition to those listed above. For example, if the annual test
b. Current Audiogram Date. Enter year, month, day (e.g., if January 31, 2000,
indicates a "negative" threshold shift and is confirmed on the first followup,
enter 20000131) that audiometric test is given and current threshold levels
the reference audiogram may be reestablished at this time without any
determined for this individual at six frequencies in each ear. Results are entered in
further followup testing for DA personnel.
5 dB increments (e.g., 0, 5, 10, 15, etc.). If responses exceed maximum limits of
audiometer, enter that limit with plus sign (e.g., 110+).
DD FORM 2216 (BACK), JAN 2000

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