DD Form 2215 Reference Audiogram
What Is DD Form 2215?
DD Form 2215, Reference Audiogram serves as a record of initial audiometric test results for comparison with the results of later test. This particular form is used to record the initial testing. An up-to-date DD Form 2215 fillable version is available for e-filing and download below. First-time filers are advised to refer to DoD Component Instructions for additional filing tips.
Periodic tests are recorded on the DD Form 2216, Hearing Conservation Data. This form is subject to the Privacy Act of 1974 - use a blanket PAC when filing (DD Form 2005, Privacy Act Statement).
The latest version of the form - sometimes confused with the DA Form 2215 - was released by the Department of Defense in January 2000 with all previous editions still available for use. The form is originally distributed by the Executive Services Directorate and is unclassified and approved for public release.
How to Fill Out DD Form 2215?
The form consists of two pages with the DoD-released filing guidelines provided on the second page. DD Form 2215 instructions are as follows:
- Block 1 is for the ZIP code/APO/FPO/PAS of the location where the testing is performed.
- Block 2 is for the DOD component of the individual. Block 3 is for their service component.
- Blocks 4 and 5 require a social security number and the full name of the individual being tested. Their date of birth and gender is indicated in Blocks 6 and 7.
- If the individual is a servicemember, their pay grade is specified in Block 8. Block 9 is for the civilian employee’s pay grade. The occupation code is indicated in Block 10. The mailing address of the assignment goes to Block 11.
- Block 12 - Place of Work - requires specifying the location where the individual is routinely exposed to hazardous noise (including building number). Box 13 is for the major command abbreviation.
- Block 14 is intended for the individual’s duty telephone number.
- The reason for the audiometric testing is identified in Block 15 by checking the appropriate box.
- Block 16 contains the results of each testing. The date the audiometric test is given is entered in Block 17.
- Block 18 should indicate whether the individual meets their referral DoD component criteria. The time of the testing is indicated in Block 19 if it is necessary.
- The time period in hours since the last noise exposure before the audiogram is indicated in Block 20.
- Any problems with the nose or the throat the individual experiences at the time of the test should be recorded in Block 21.
- Block 22 is for the information about the examiner. The required information includes their full name, training certification number, service duty occupation code, and office symbol.
- Block 23 should provide information on the audiometer (its model, type, manufacturer, serial number and the date of the last calibration).
- Block 24 requires the data about the hearing protection issued to the individual - if any. Any additional information (including the individual’s 8-hour TWA noise exposure - if known) can be listed in Block 25.