Form 0920-22DI Attachment G_Audiometry testing data capture

Form Approved

OMB No. XXX

Exp. Date XX/XX/XXXX

AUDIOMETRY DATA CAPTURE FORM:

Audiometer Serial #: _______________ Left Earphone Serial #: _______________

Right Headphone Serial #: _______________

Health Technician: _________________________ Date: ________________ Tester ID: ______

Participant ID: _____________________________

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXX).

AUDIOMETRY INTERVIEW:

1. Have you had a cold, stuffy or runny nose since yesterday {during the last 24 hours}?	1. Yes 2. No 77. Prefer not to answer 99. Don’t know
2. Have you had a fever or high temperature [> 100°F)], sore throat, or body aches and pains recently {during the last 2 weeks}?	1. Yes 2. No 77. Prefer not to answer 99. Don’t know
3.1 Have you had a pain in your ears, an earache, or plugged or stuffy ears recently {during the last 2 weeks}?	1. Yes 2. No 77. Prefer not to answer 99. Don’t know
3.2 If yes, which ear?	1. Left 2. Right 3. Both 77. Prefer not to answer 99. Don’t know
4.1 Have you had a pain in your ears, an earache, or plugged or stuffy ears since yesterday {during the last 24 hours}?	1. Yes 2. No 77. Prefer not to answer 99. Don’t know
4.2 If yes, which ear?	1. Left 2. Right 3. Both 77. Prefer not to answer 99. Don’t know
5.1 Do you have a tube in your right or left ear now?	1. Yes 2. No 77. Prefer not to answer 99. Don’t know
5.2 If yes, which ear?	1. Left 2. Right 3. Both 77. Prefer not to answer 99. Don’t know
6. Have you listened to very loud TV, music, or any other very loud sounds or noises since yesterday {during the past 24 hours}?	1. Yes 2. No 77. Prefer not to answer 99. Don’t know
7. Have you been bothered by your ears ringing or making other sounds like buzzing, whistling, or roaring recently {during the last 2 weeks}?	1. Yes 2. No 77. Prefer not to answer 99. Don’t know
8.1 Do you hear better in one ear than the other?	1. Yes 2. No 77. Prefer not to answer 99. Don’t know
8.2 If yes, which ear?	1. Left 2. Right 3. Both 77. Prefer not to answer 99. Don’t know