Sample Audiometric and Identification Information

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Audiometric and Identification Information

Name:_____________________________________________________________________________
Soc. Sec. #:____-___-_____ Birth Date: ___/___/___ Gender: M F (Circle)
Empl. No. _____________________ Job Code: ____________ Dept. No. _______________
Test Date: ___/___/___ Time: __:__ Test Type:______ Time since last eposure______h
Exposure Level ____dBA
 

Hearing Protector Activity 
 

Yes_____ No______
Issue_________
Training_______
Retraining______

 

Hearing Protector Used (Circle)
 

Self Reported Employee Histories

(Y/N) Medical History (Y/N) Hobby & Military History (Y/N) Additional Information
___Diabetes ___Hunt/Shoot ___Noisy 2nd Job
___Ear Surgery ___Car Racing ___Noisy Past Job
___Head Injury ___Motorcycles ___Exposure to Solvents
___High Fever ___Other Loud Vehicles ___Exposure to Metals
___Measels/Mumps ___Loud Music/Band ___Difficulty Hearing
___Smoking ___Power Tools ___Hearing Aid
___Hypertension ___Other Noisy Hobbies ___Recent Change in Hearing
___Ringing in Ears ___Military Service ___See Physician About Ears
___Ear Infection ___  Fire Weapon ___See Prior Histories
___Other ___Other ___Other

Audiogram
Test Frequency

  500 1000 2000 3000 4000 6000 8000
Right Ear              
Left Ear              
Audiometer:______________ Serial Number________________
Exhaustive Cal. Date: ___/___/___ Biological Cal. Date: ___/___/___
Tester Identification: ____-___-____ Test Reliability (Good, Fair, Poor): ______
Review Identification: ____-___-____ Audiogram Classification Code: ___ ___ ___

      Comments:_____________________________________________________________________
      ______________________________________________________________________________