DD Form 2215 – Reference Audiogram

DDFORMS.ORG – DD Form 2215 – Reference Audiogram – An audiogram is a vital tool used by hearing healthcare professionals to measure how well a person hears. DD Form 2215, also known as the Reference Audiogram, is an important document utilized in the assessment of hearing loss. Developed by the Department of Defense, this form provides a standardized way for clinicians to evaluate and compare hearing thresholds from one test to another.

Download DD Form 2215 – Reference Audiogram

Form Number DD Form 2215
Form Title Reference Audiogram
Edition Date 1/1/2000
File Size 713 KB

What is a DD Form 2215?

A DD Form 2215, otherwise known as the Reference Audiogram, is a form utilized by the U.S. Department of Defense (DoD) to document hearing test results for individuals in active military service. The audiogram records pure tone air-conduction tests in both ears and bone conduction tests for each ear separately. Additionally, it captures speech reception threshold levels and speech discrimination scores for both ears combined. The form also asks for comments relating to any abnormal findings that were identified during the hearing evaluation process.

The DoD requires all military personnel who are exposed to potentially hazardous noise levels on the job to receive regular audiometric testing from a licensed audiologist or physician specializing in otolaryngology (ear, nose & throat care). Results must be documented using DD Form 2215 prior to assignment in noisy environments or participation in certain activities such as firing weapons while wearing personal protective equipment (PPE). This ensures that service members’ hearing is not adversely affected by their occupational duties and promotes safe working conditions within military operations at home and abroad.

Where Can I Find a DD Form 2215?

The DD Form 2215 is available for download online from the Department of Defense’s Electronic Forms Management website. Once on the site, select “Forms” from the main navigation menu and search for “DD Form 2215” in the search bar. The form can be printed and filled out to document a reference audiogram conducted by a licensed audiologist. It is typically used to determine if an individual has sustained hearing loss due to noise exposure while serving in the military and should be part of their permanent medical record.

In addition to downloading it online, individuals may also be able to request copies of DD Form 2215 directly from their service branch or regional TRICARE office as well as through their military health care provider. Some military bases may even have them available at their medical clinic or sound-proof booth where they conduct hearing tests and evaluations. Lastly, veterans who served in World War I, World War II, Korea, or Vietnam may be able to find copies of these forms stored in their National Archives records file if they have one.

DD Form 2215 – Reference Audiogram

The DD Form 2215 is the official audiology reference standard for the U.S. Department of Defense, commonly known as a “Reference Audiogram.” It is used to measure and document the hearing levels of military personnel and serves as an objective measure of auditory function. The form includes a graph with frequencies from 250 to 8000 hertz and decibels from 0 to 120 dB, along with columns for recording thresholds in each ear at 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hertz. This form also includes descriptive information such as the age of the testee when tested; type of calibration signal (tone or speech); any corrections applied; equipment used; and name/rank/serial number of the testee. Additionally, it has a section for comments regarding any abnormal findings or other relevant information related to the audiometric evaluation. The DD Form 2215 must be administered by a certified audiologist or physician according to current DoD standards in order to ensure accuracy in results. Once complete, it should be kept on file by both medical personnel and service members themselves so that they can monitor changes in their hearing over time if needed.

DD Form 2215 Example

DD Form 2215

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