SOW_Attachment 4-Audiology Questionnaire.pdf
PDF 530 KB Posted
- Attached to
- OMAO/Occupational Health Support Services
- Solicitation number
- 1305M224Q0073
About this file
This document is an Audiology History Questionnaire from the U.S. Department of Commerce National Oceanic and Atmospheric Administration (NOAA). The questionnaire gathers information on the respondent's hearing history, including any difficulties understanding speech, ringing in ears, dizziness, ear pain, hearing loss, and exposure to loud noises from recreational activities. The respondent is asked to answer "YES/NO" to a series of statements related to their hearing health. The completed questionnaire is to be provided to the Medical Officer for review. This appears to be an attachment to a broader federal contract opportunity, which is identified as Solicitation Number 1305M224Q0073 for "OMAO/Occupational Health Support Services" from the Department of Commerce NOAA. The solicitation document and additional attachments would contain details on the products or services being procured, response dates, pricing terms, set-asides, and other salient information.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment B-Schedule of Items and Prices_Amend0005.xlsx | XLSX spreadsheet | |
| Attachment A-SOW_Amend0005.pdf | ||
| Attachment 4-QASP.pdf | ||
| Amendment 0005.pdf | ||
| Questions and Answers_Amend0005.xlsx | XLSX spreadsheet | |
| SOW_Attachment 5 Respirator Questionnaire.pdf | ||
| Amendment 0004.pdf | ||
| Amendment 0003.pdf | ||
| Amendment 0002.pdf | ||
| Amendment 0001.pdf | ||
| Attachment C- Past Performance Information Form.pdf | ||
| Attachment A-Statement of Work-Occupational Health Services.pdf | ||
| Attachment D-Past Performance Questionnaire.pdf | ||
| Sol_1305M224Q0073.pdf | ||
| Attachment B-Schedule of Items and Prices.xlsx | XLSX spreadsheet |
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Text version
U.S. DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
Audiology History Questionnaire
1. LAST NAME, FIRST NAME, MIDDLE INITIAL
Answer with a YES/NO if statement applies to you:
3. STATUS:
Hearing Conversion Program (HCP) Audiograms Only
2. SSN
5. In the last year have you experienced:
Difficulty understanding speech:
A. Under all circumstances:
B. In background noise
C. On telephone:
Ringing in ears:
A. Constant:
B. Intermittent:
C. High-pitched ring:
D. Low-pitched buzz
Dizzy spells (spinning)
Presence or persistence of ear pain:
Rapidly progressing hearing loss feeling of fullness or discomfort in either ear:
6. History of:
Sudden or fluctuating hearing loss
Eardrum rupture
Chronic ear infections
Taking drugs that affect hearing
Skull facture
Ear Surgery
Relevant medical problems
Chronic exposure to loud noise without protection:
Poor hearing in one ear
Hearing aid use
Other high noise exposure
Walk man/headset use
Amplified music(concerts):
Power tool use (routers, saws etc.)
Drag racing/motorcycle racing
Firearm use (hunting, target shooting etc.)
7. Recreational noise exposure:
Do you wear hearing protection, both on and off the job, When appropriate?
Medical Officer Review (initials): 8. NAME 9. INITIAL
Provide information to (YES) statements on SF-600
U.S. DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration Audiology History Questionnaire
1. LAST NAME, FIRST NAME, MIDDLE INITIAL
Answer with a YES/NO if statement applies to you:
3. STATUS:
Hearing Conversion Program (HCP) Audiograms Only
2. SSN
5. In the last year have you experienced:
Difficulty understanding speech:
A. Under all circumstances:
B. In background noise C. On telephone:
Ringing in ears:
A. Constant:
B. Intermittent:
C. High-pitched ring:
D. Low-pitched buzz Dizzy spells (spinning) Presence or persistence of ear pain:
Rapidly progressing hearing loss feeling of fullness or discomfort in either ear:
6. History of:
Sudden or fluctuating hearing loss Eardrum rupture Chronic ear infections Taking drugs that affect hearing Skull facture Ear Surgery Relevant medical problems Chronic exposure to loud noise without protection:
Poor hearing in one ear Hearing aid use Other high noise exposure Walk man/headset use Amplified music(concerts):
Power tool use (routers, saws etc.)
Drag racing/motorcycle racing Firearm use (hunting, target shooting etc.)
7. Recreational noise exposure:
Do you wear hearing protection, both on and off the job, When appropriate?
Medical Officer Review (initials):
8. NAME
9. INITIAL
Provide information to (YES) statements on SF-600 8.0.1291.1.339988.308172
| 2. TRAVELER'S LAST NAME, FIRST NAME, MIDDLE INITIAL: |
| 3. DATE OF REQUEST:: Yes |
| 3. DATE OF REQUEST:: No |
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