Get Blank Audiogram

Filling out the Blank Audiogram form online is essential for recording the audiometric test results for individuals exposed to hazardous noise. This guide will provide clear and supportive instructions on how to accurately complete each section of the form.

Follow the steps to fill out the Blank Audiogram effectively.

1. Press the ‘Get Form’ button to access the audiogram document and open it in your preferred editing software.
2. Enter the ZIP code/APO/FPO/PAS in the designated field, ensuring you use the nine-digit format for accuracy.
3. Select the appropriate DOD component by entering the corresponding letter in the provided box.
4. Indicate the service component by entering the correct letter from the options list (e.g., A for Army, N for Navy).
5. Provide your social security number as a nine-digit entry.
6. Fill in your full name, including last name, first name, and middle initial.
7. Enter your date of birth using the format YYYYMMDD.
8. Select your sex by entering 'M' for male or 'F' for female.
9. For military personnel, enter your pay grade using the codes specified in the form.
10. If applicable, complete the civilian pay grade entry with the appropriate construction (e.g., WG, GS).
11. Fill in your service duty occupation code reflecting your current role.
12. Provide your mailing address of assignment, including installation details and ZIP code.
13. Enter the location where you work, specifying any pertinent details such as building numbers.
14. Indicate your major command using the authorized abbreviation.
15. Input your duty telephone number, including the area code.
16. Select the purpose for completing the audiogram by checking the respective box.
17. Enter the current audiogram date in YYYYMMDD format.
18. Provide the reference audiogram date, again in YYYYMMDD format.
19. Indicate whether a significant threshold shift is present by selecting 'Yes' or 'No.'
20. Complete the threshold shift data as needed, providing pertinent remarks.
21. Document the type of personal hearing protection used by selecting the appropriate option.
22. Fill in the examiner's name and their training certificate number.
23. Complete the sections regarding the audiometer type, model, manufacturer, and its calibration date.
24. Once all sections are completed, you can save your changes, download, print, or share the audiogram as required.

Start filling out your Blank Audiogram online today for a timely and accurate assessment.