Sample Audiometric and Identification Information

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:_____________________________________________________________________
______________________________________________________________________________