Form NIST-426 Audiological History

OMB Control Number: 0693-0080 Expiration Date: 08/31/2024
U.S. DEPARTMENT OF COMMERCE

NAME

NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

Last

First

DATE OF BIRTH

Middle

OPERATING UNIT & LOCATION

DATE EMPLOYED

JOB ASSIGNMENT

DATE

AUDIOLOGICAL HISTORY
OCCUPATIONAL HISTORY (Beginning with last previous, working back to first job.)

1.

NOISE
EXPOSURE
YES

NO

EAR
PROTECTORS
YES
NO

2.

YES

NO

YES

NO

3.

YES

NO

YES

NO

4.

YES

NO

YES

NO

EMPLOYER

MILITARY
SERVICE

CITY

TIME SERVED

DUTIES

BRANCH

DATES OF
SERVICE

(OTHER)
EXPOSURE TO GUNFIRE AND NOISE

ARMY

NAVY

MARINES

YES

NO

AIR FORCE

CHECK IF YOU HAVE HAD ANY OF THE FOLLOWING:
ALLERGY
MEASLES
MENINGITIS

DIABETES
SCARLET FEVER
ENCEPHALITIS

MUMPS
WHOOPING COUGH
HEAD INJURY

HAVE YOU EVER BEEN NOTIFIED THAT YOU HAVE A HEARING LOSS? DATE
HEARING LOSS IN FAMILY
SEVERE OR PROLONGED ILLNESS
HAVE YOU OR ANY MEMBER OF YOUR FAMILY HAD ANY EAR OPERATIONS?
DESCRIBE:

CHECK IF YOU NOW HAVE ANY OF THE FOLLOWING:
PAIN IN EARS
EAR DISCHARGE
TAKING ANY MEDICATIONS NAME

RINGING IN EARS

NON-OCCUPATIONAL NOISE EXPOSURE

YES

NO

HOW OFTEN?

HUNTING OR SHOOTING
LOUD MUSIC
SNOWMOBILE
AIRPLANE
MOTORCYCLE
OTHER
PREVIOUS HEARING TEST

IS YOUR HEARING

DATE

COMPANY

GOOD

FAIR

ARE YOU NOW USING EAR PROTECTION?

NIST-426 (REV. 4-2021) NIST P 7100.00

YES, TYPE USED

POOR
NO

(IF NO, EXPLAIN BRIEFLY)

YES

NO

OMB Control Number: 0693-0080 Expiration Date: 08/31/2024

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply
with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid
OMB Control Number. The approved OMB Control Number for this information collection is 0693-0080. Without this approval, we could not conduct this
information collection. Public reporting for this information collection is estimated to be approximately 10 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information
collection. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information
collection, including suggestions for reducing this burden to the National Institute of Standards and Technology, Attn: Stephen Banovic,
[email protected].
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why the U.S. Department of Commerce (the Department), National Institute of
Standards and Technology (NIST) is requesting the information on this form.
AUTHORITY:
The collection of this information is authorized under The National Institute of Standards and Technology Act, as amended, 15 U.S.C. 271 et seq. (which includes Title 15
U.S.C. 272) and section 12 of the Stevenson-Wydler Technology Innovation Act of 1980, as amended, 15 U.S.C. 3710a. Includes the following, with all revisions and
amendments: 5 U.S.C. 301; 44 U.S.C. 3101; E.O. 12107, E.O. 13164, 41 U.S.C. 433(d); 5 U.S.C. 5379; 5 CFR Part 537; DAO 202-957; E.O. 12656; Federal Preparedness
Circular (FPC) 65, July 26, 1999; DAO 210-110; Executive Order 12564; Public Law 100-71, dated July 11, 1987. Executive Orders 12107, 12196, and 12564 and 5
U.S.C. chapters 11, 33, and 63.
PURPOSE:
The Office of Safety, Health, and Environment (OSHE) supports the National Institute for Standards and Technology in carrying out its mission safely and in maintaining
safety as an integral core value and vital part of the NIST culture. The NIST Health Unit will use this information to record medical or health information for individuals
seeking medical care on NIST campus; for recording of medical or safety equipment or incidents; to refer information required by applicable law to be disclosed to a
Federal, State, or local public health service agency, concerning individuals who have contracted certain communicable diseases or conditions. Such information is used to
prevent further outbreak of the disease or condition; to disclose information to the appropriate Federal, State, or local agency responsible for investigation of an accident,
disease, medical condition, or injury as required by pertinent legal authority; to disclose information, when an individual to whom a record pertains is mentally
incompetent or under other legal disability, to any person who is responsible for the care of the individual, to the extent necessary; to disclose to the Office of Workers'
Compensation Programs in connection with a claim for benefits filed. Disclosure of this information is also subject to all the published routine uses as identified in the
Privacy Act System of Records Notices:
Commerce/DEPT-18: Employees Personnel Files Not Covered by Notices of Other Agencies
OPM/GOVT-10: Employee Medical File System Records.
ROUTINE USES:
The information solicited on this form may be made available as a “routine use” pursuant to 5 U.S.C. § 552a(a)(7) and (b)(3). The information may be made available to
other federal agencies to assist the Department in connection with NIST’s management of the purposes stated above; or for other authorized routine uses.
A complete list of the routine uses can be found in the system of records notice associated with this form, “COMMERCE/DEPT-23: Information Collected Electronically
in Connection with Department of Commerce Activities, Events, and Programs; and COMMERCE/DEPT-13: Investigative and Security Records. These system of records
notices can be found on the Department's website at https://www.osec.doc.gov/opog/privacyact/privacyact_sorns.html and OPM/GOVT-10: Employee Medical File
System Records at https://www.opm.gov/information-management/privacy-policy/sorn/opm-sorn-govt-10-employee-medical-file-systems-records.pdf

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:
Providing this information is voluntary. However, failure to provide the requested information may result in an inability for NIST to process, review, and/or act on such
requests. In limited circumstances, NIST may authorize the submission of the requested information via paper forms pursuant to the requirements in 15 CFR 748.1(d).

NIST-426 (REV. 4-2021)