Page 33 - DIDC SOPS and Guidelinesv as of April 2019

Hearing Conservation Audiometric PMO-9002-01-06-a
Questionnaire

DI LOGCAP IV Released Date Page 1 of 1
05/29/14

AUDIOMETRIC QUESTIONNAIRE

Name: Date: Gender: M F

Employee #: Birth Date:

Company Name: Dept. Job Shift

What type of hearing protection do you wear? Foam Plugs Hard Rubber Plugs Ear Muffs None

Have you had any of the following?

YES NO YES NO
Serious Head Injury Do you wear hearing aids?
YES NO YES NO
Measles Are you a hunter/shooter?
YES NO
Mumps Do you have any noisy For technician use only:
YES NO
Diabetes hobbies? Check below:
YES NO Motorcycling Leaf Ear Right Ear
Cancer
YES NO Woodworking XSP XSP
Chronic Ear Infections
YES NO Car Races
Ear Drainage SP SP
YES NO Flying Planes
Ruptured Ear Drum MP MP
YES NO Others
Ear Surgery LP LP

YES NO XLP XLP
Recent Cold or
Sinus Problem

YES NO
Hearing Loss If Yes, Please explain

Previous Workplace
YES NO
Noise Exposure Where # of Years Exposed? ____

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