Attachment V_NMCPHC_TM_6260.51.99-3-NavyMedicine_HCP_TM_July_2020.pdf

NMCPHC TM-6260.51.99-3 (July 2020)

NAVY AND MARINE CORPS PUBLIC HEALTH CENTER

PREVENTION AND PROTECTION START HERE

NMCPHC TM-6260.51.99-3

(July 2020)

Navy and Marine Corps Public Health Center Technical Manual

NAVY MEDICINE HEARING CONSERVATION

PROGRAM TECHNICAL MANUAL

THIS PUBLICATION SUPERSEDES NMCPHC TM-6260.51.99-2 OF SEPTEMBER 2008

DISTRIBUTION A: APPROVED FOR PUBLIC RELEASE; DISTRIBUTION IS UNLIMITED.

THIS PUBLICATION IS AVAILABLE ELECTRONICALLY VIA THE NMCPHC WEBSITE AT

https://go.usa.gov/xPrVk.

620 John Paul Jones Circle, Suite 1100

Portsmouth, VA 23708-2103

TABLE OF CONTENTS:

I. ACRONYMS

II. INTRODUCTION

III. NOISE MEASUREMENT AND CONTROL

IV. HEARING PROTECTION

V. AUDIOMETRIC MONITORING

VI. EMPLOYEE TRAINING

VII. RECORDKEEPING

VIII. PROGRAM EVALUATION AND MANAGEMENT

APPENDIX A: LIST OF SUPPORTING DOCUMENTS

APPENDIX B: REFERENCES

I. Acronyms

ANSI American National Standards Institute

ASN Assistant Secretary of the Navy

BUMED Bureau of Medicine & Surgery

CFR Code of Federal Regulation

CAOHC Council for Accreditation in Occupational Hearing Conservation

DoDI Department of Defense Instruction

DON Depart of the Navy

DOEHRS-HC Defense Occupational and Environmental Health Reporting System-

Hearing Conservation

DR Data Repository

ECAA Enterprise Clinical Audiology Application

ESAMS Enterprise Safety Application Management System

FFD Fitness for Duty

HCP Hearing Conservation Program

HCPM Hearing Conservation Program Manager

HCT Hearing Conservation Technician

HPD Hearing Protection Device

HRO Human Resource Office

IH Industrial Hygiene

JKO Joint Knowledge Online

MEB Medical Evaluation Board

MEDIG Medical Inspector General

MHS Military Health System

MOA Memorandum of Agreement

MOE Measurements of Effectiveness

MOHCAT Mobile Hearing Conservation Audiometric Truck

MOS Military Occupational Specialty

MRI Magnetic Resonance Imaging

MRRS Medical Readiness Reporting System

MTF Military Treatment Facility

NEC Navy Enlisted Classification

NMCPHC Navy and Marine Corps Public Health Center

NIHL Noise Induced Hearing Loss

NRR Noise Reduction Rating

OA/HC Occupational Audiology and Hearing Conservation

OBA Octave Band Analyzer

OIC Officer in Charge

OMPA Occupational Medicine Program Assessment

OPNAV Office of the Chief of Naval Operations

OPNAVINST Office of the Chief of Naval Operations Instruction

OSHA Occupational Safety and Health Administration

PB Phonetically Balanced

PCO Prospective Commanding Officer

PHI Protective Health Information

PII Personally Identifiable Information

PTS Permanent Threshold Shift

PXO Prospective Executive Officer

SDOC Service Duty Occupational Code

SECNAV Secretary of the Navy

SEG Similarly Exposure Group

SOH Safety and Occupational Health

SOP Standard Operating Procedures

SRT Speech Reception Threshold

STS Significant Threshold Shift

TCAPS Tactical Communication and Protection Systems

TWA Time-Weighted Average

WESS Web-Enabled Safety System

II. INTRODUCTION

Hearing is a multidimensional sense that functions 24 hours a day, 7 days a week in a 360 degree sphere. Good hearing is important for communicating with others in our personal lives and at work.

In certain situations, distinct hearing and precise communications are critical, where a lack of clear understanding can trigger serious consequences. Military occupational environments exemplify those venues. The military is a noisy enterprise. Tactical training, operational combat, shipboard operations and shore industrial environments are inherently noise hazardous occupations. Noise

Induced Hearing Loss (NIHL) and tinnitus are the most prevalent occupational health risks in the military. Unprotected exposure to hazardous noise can cause temporary or permanent hearing loss, compromise verbal communications, degrade the ability to discern important auditory signals in the environment, and jeopardize human safety and operational efficiency.

The objectives of Occupational Audiology (OA) and the Hearing Conservation Program (HCP) are to prevent occupational NIHL through proactive implementation of outreach, education and prevention activities, and to preserve and enhance hearing capability by adhering to regulatory measures, implementing program guidelines, and applying technological advances.

A. Purpose

1. The purpose of the Navy Medicine HCP Technical Manual (TM) is to provide supplemental regulatory guidance to the Occupational Safety and Health Administration (OSHA), Department of Defense (DoD), and Office of the Chief of Naval Operations (OPNAV) 5100 series of instructions for the consistent and effective implementation of the Navy and Marine Corps HCP.

B. Guidance

Title 29, Code of Federal Regulation (CFR), Section 1910.95, Occupational Noise Exposurea contains the OSHA regulation regarding hearing conservation. OSHA guidance provides the minimum standards regarding the regulation and monitoring of hearing conservation for business and industry. Specific HCP guidance for uniformed Armed Service members, military equipment, military systems and military operations is outlined in DoD regulations.

In addition, Title 29, CFR, Part 1904 Recording and Reporting Occupational Injuries and Illnessesb mandates recording and reporting of work-related hearing loss to OSHA for civilians enrolled in the

HCP.

DoD and OPNAV instructions are based on federal OSHA law but are often more stringent due to longer exposure times and noise levels. Combat operations are exempt from meeting OSHA regulations. Local Commands establish specific installation policies or standard operating procedures (SOPs) to implement the HCP.

1. Department of Defense Instruction (DoDI) 6055.12c, Hearing Conservation Program establishes policy to protect all DoD personnel from hearing loss resulting from operational and occupational noise exposure through a continuing, effective, and comprehensive HCP. DoD

Service Components must develop and maintain a written plan and ensure the implementation of a comprehensive HCP.

2. The Assistant Secretary of the Navy (ASN) determines Safety and Occupational Health

(SOH) policy for the Department of the Navy (DON). OPNAVINST 5100.23, Navy Safety and

Occupational Health Program Manuald is published to provide overall Navy policy for the management of the total SOH program. OPNAVINST 5100.23 provides policy, procedures, and guidance pertaining to responsibilities set forth by the ASN and Chapter 18 is specific to Hearing

Conservation and Noise Abatement.

General concepts and provisions of OPNAVINST 5100.23 apply to all Navy; however, exceptions are made for military-unique equipment, systems, and operations such as forces afloat.

OPNAVINST 5100.19, Navy Safety and Occupational Health Program Manuale for Forces Afloat is the primary SOH resource document for implementing the SOH Program for afloat commands. The purpose of OPNAVINST 5100.19 is to provide commanding officers, safety officers, managers, supervisors, and workers for afloat commands with a document that gives guidance and direction necessary to implement the SOH Program. Section B of OPNAV 5100.19 is divided into Major

Hazard-Specific Elements and Chapter B4 pertains specifically to Hearing Conservation.

3. In addition to the OPNAVINST 5100 series, the Marine Corps Order 6260.3 series, Marine

Corps Hearing Conservation Programf establishes the HCP policy for Marine Corps personnel.

USMC personnel must meet reference and annual audiogram requirements and audiogram dates must be recorded and tracked in the Medical Readiness Reporting System (MRRS).

4. Appendix A provides a list of supporting documents that can be found on the Navy and

Marine Corps Public Health Center (NMCPHC) website.

C. Responsibilities

1. Bureau of Medicine and Surgery (BUMED) Audiologist. Establishes policy and procedures to implement and manage a comprehensive Department of the Navy Hearing

Conservation Program.

a. Serves as the subject matter expert for hearing conservation-related matters for activities under the command and control of Chief, BUMED.

b. Coordinates the exchange of hearing conservation information between headquarters commands to ensure familiarity with BUMED policies and procedures, and that they are implemented consistently across Navy Medicine.

2. NMCPHC Occupational Audiology and Hearing Conservation (OA/HC) Division Head.

Provides appropriate guidance and direction and serves as consultant to Navy audiologists, occupational health physicians, occupational health nurses and other health professionals in matters related to occupational audiology, hearing conservation, and noise control.

a. Provides input into the formulation of Navy Medicine policy concerning occupational audiology, hearing conservation, and noise control.

b. Serves as the Navy’s Defense Occupational and Environmental Health Reporting

System-Hearing Conservation (DOEHRS-HC) Program Manager for system development, field evaluation and operation. In this capacity, the NMCPHC OA/HC Division Head provides professional analysis of DOEHRS-HC data and develops authoritative scientific reports.

c. Reviews military treatment facility (MTF) requests for occupational audiology, hearing conservation and noise measurement equipment.

d. Provides technical oversight of the NMCPHC Calibration Laboratory which is responsible for distributing, repairing, maintaining, and calibrating audiometric, sound measuring, and other related occupational health equipment.

e. Provides standardization and quality assurance and oversight of Hearing Conservation

Technician (HCT) training programs Navy-wide. Ensures training programs at a minimum meet the standards of the Council for Accreditation in Occupational Hearing Conservation (CAOHC), the nationally recognized accrediting body for hearing testing certification.

(1) All courses are required to be coordinated, scheduled and/or canceled with

NMCPHC no later than one week prior to the end of the preceding month the course is being held.

This can be done via email to the NMCPHC Information Systems and Training Specialist.

Information required includes: Start date, location, course director, DOEHRS-HC instructor, and confirmation of CAOHC certification and CAOHC course number (if applicable). Also, NMCPHC has an inventory of available training equipment that can be provided (based on availability) to support courses. Course Directors will submit the request for training equipment at the time of scheduling the HCT Certification Course. Training equipment will be shipped back to NMCPHC no later than the first business day after course completion.

(2) Course Directors must follow the standardized five day HCT Certification Course curriculum that entails a written test, practical test, and oral patient counseling exam in order to meet certification requirements. There is a limit of one student per computer, audiometric hardware, and DOEHRS-HC software training set. It is recommended that Course Directors have students print manuals locally prior to class.

(3) For the course to be closed out and certifications to be approved by NMCPHC student rosters and student course critiques must be submitted within three business days of course completion.

f. Maintains liaison with and provides appropriate input to the Naval Medical Research and Development Command. Plans, recommends, coordinates and evaluates pilot projects with innovative audiometric techniques, procedures and equipment.

3. NMCPHC Information Systems and Training Specialist. Provides resolutions to users with

DOEHRS-HC and Data Repository (DR) software and hardware issues. Assists users with system trouble calls and ensures that problems are resolved. Shares solutions to common problems with the

Audiology community, Program Managers and DOEHRS user communities and reports unusual problems to the DOEHRS-HC and DR Functional Managers.

a. Plans and develops educational strategies and materials to ensure all users at all audiometric test sites are fully competent with DOEHRS-HC and DR software and hardware use.

Provides on-site training on the DOEHRS-HC system, as needed, to users and HCP Managers.

b. Monitors all audiometric test sites and works to ensure that all users are entering accurate and appropriate data into the DOEHRS-HC system. Works to ensure all sites maintain current DOEHRS-HC software, look-up tables, Unit Identification Code Finder software and other resources needed, specific to each test site, for optimum quality data collection.

c. Performs routine analysis of data. Monitors all exported DOEHRS-HC data to the DR for appropriate quantity and quality of data. Proactively educates and assists users and sites with data export and compliance issues to improve data quality/quantity.

4. NMCPHC Calibration Laboratory. Manages maintenance plans, practices and updates programs for all assigned equipment.

a. Resolves problems pertaining to the design, installation, maintenance, operation, calibration and repair of the assigned Industrial Hygiene, audiometric and other medical equipment pertaining to the HCP.

b. Maintains database for inventory control of audiometers, calibrators, sound level meters and dosimeters. Uses Defense Medical Logistics Standard Support (DMLSS) for the inventory control of HCP audiometers.

c. Per NAVMED P-5132, Equipment Management Manualg, NMCPHC will procure, own, calibrate, and manage all Navy Medicine HCP audiometers.

d. Provides Navy-wide support for audiometer and sound level measuring equipment calibration, maintenance, repair and replacement. For any audiometers needing repair, immediate contact should be made to the NMCPHC Calibration Laboratory to coordinate the transfer of new equipment to replace the faulty equipment. Faulty equipment will be returned to NMCPHC for troubleshooting.

e. Provides technical assistance for equipment operation, life cycle management and equipment replacement.

f. Maintains the DOEHRS-HC training equipment utilized by the Hearing Conservation

Program.

5. Regional Hearing Conservation Program Manager (HCPM). Regional HCPMs serve as the senior Occupational Audiology and Hearing Conservation subject matter experts for the Navy

Medicine Regions, and are responsible for oversight and implementation of Navy/USMC HCPs throughout the Region.

a. Establishes regional business rules and benchmarks, and facilitates policy development/improvement.

b. Formally evaluates the HCPs of echelon 4 subordinate activity MTFs at least every three years as part of the Safety and Occupational Health Management Evaluation (SOHME) in accordance with appendix B references (d) and the Bureau of Medicine Instruction 5100.13, Safety and Occupational Health Programh. At the discretion of the Regional HCPM or the request of an

MTF, technical or informal program assist visits may be provided.

c. Collaborates with Medical Inspector General (MEDIG) SOH inspectors to ensure quality, stable, sustainable, effective programs and promote standardization of best practices across the enterprise.

d. Facilitates Occupational Audiologist cross-leveling support coverage at MTFs within the region. When MTFs have gapped Occupational Audiologist billets, Regional HCP Managers work to identify and designate another Occupational Audiologist within the region (military or civilian) to temporarily backfill a gapped position. When there is no available Occupational

Audiologist within the region to support the gapped billet, the Regional Human

Resources/Manpower Office forwards the cross-leveling support request to the other Navy

Medicine Region or to the Navy Audiology Specialty Leader to identify a potential candidate to provide temporary coverage to the requesting command.

e. Briefs Prospective Commanding Officers (PCO) and Prospective Executive Officers

(PXO) on the status of the gaining MTF’s HCP.

f. Upon completion of each fiscal year, Regional HCP Managers review HCP Self-

Assessments from each of the MTFs under their purview to evaluate the status of each MTF’s program and (when possible) provide support and/or resources to facilitate improvements at commands where weaknesses or challenges exist.

g. Reviews and consolidates MTF HCP metrics and forwards to BUMED M44 at the end of each fiscal year.

6. MTF Hearing Conservation Program Manager. An MTF HCP Manager will be designated by appointment letter. The senior MTF Occupational Audiologist is the appropriate professional to serve as MTF HCP Manager. In the absence of an OA, the Regional HCP Manager will assist the

MTF commanding officer in identifying an individual within the MTF’s Area of Responsibility

(AOR) to provide local program management and an OA to provide program oversight support via

Memorandum of Agreement (MOA). MTF HCP Managers are responsible for implementing the

Navy Medicine components of the HCP for noise hazard commands within the MTF AOR.

a. Ensures standardization of patient care and business practices across the MTF AOR.

Provides centralized oversight, operational management, and technical supervision of OA and HCP personnel, services and resources within the MTF, branch clinics, and mobile facilities. Convenes at least semi-annual meetings and/or training with HCP staff to facilitate effective leadership, communication, and program/process improvement efforts.

b. Ensures adequate staffing, equipment, supplies, operating target, and access to OA and

HCP care and services at MTFs in the AOR. The BUMED Occupational Audiology Staffing Model

(OASM) will be used as a guide to determine appropriate staffing levels.

c. Oversees staffing issues to include initiating, participating and facilitating in hiring actions and orientation of OAs and HCP personnel. Facilitates training, certification, and continuing education for HCP staff.

d. Provides technical review of HCP notifications, correspondence and reports.

e. Conducts medical record reviews, mentoring, and performance and competency evaluations for HCP staff.

f. Monitors and evaluates DOEHRS data quality from HCP point of care sites and resolves discrepancies. Ensures all HCP workload is appropriately captured in patient Electronic

Health Record (EHR) systems and all time spent performing HCP functions is accurately captured in the Defense Medical Human Resource System – Internet (DMHRSi) under the “FBN” Medical

Expense and Performance Reporting System (MEPRS) code.

g. Manages MTF HCP equipment inventory, maintenance, calibration schedules, and clinic space needs. Coordinates with leadership on facility design of new and renovated spaces and/or the relocation of OA and HCP personnel. Consults with the Regional OA/HCPM prior to purchasing new audiometric booth(s).

h. Completes annual HCP Self-Assessment and metrics per reference (h). Annually briefs

MTF leadership on overall HCP status, self-assessment findings, metrics, and plans for improvement. Submits assessment and metrics data to the cognizant Navy Medicine Regional HCP

Manager per established timelines.

i. Maintains HCP preparedness across the MTF enterprise for SOHME and Navy MEDIG inspections. Resolves all formal findings.

j. Maintains a comprehensive list and contact information of all HCP enrolled commands and command Safety Managers/Officers and updates it semi-annually. See section 7.b.(1) below for required enrollment data elements.

k. Participates in ongoing communication and collaboration with noise hazard commands to evaluate HCP effectiveness and work toward the common goal of hearing loss prevention.

l. Monitors and tracks program effectiveness of all supported activities. Provides documented annual HCP performance reports to supported commands/activities and maintains these documents for at least 5 years for inspections, audits, or epidemiological trending.

m. Ensures that formal hearing injury notifications are provided to employees and their supervisors within 21 days of OA confirmation of permanent threshold shift (PTS) or OSHA recordable hearing loss.

n. Conducts quarterly review of DOEHRS data entry integrity and DR uploads for all

DOEHRS users in the AOR. Analyzes DOEHRS data quality, and addresses and corrects data integrity issues. Quarterly reviews DR accounts and archives inactive users.

o. The detailed program management checklist can be found on the NMCPHC website.

7. Occupational Audiologist. For the purpose of HCP Management, the Occupational

Audiologist/Hearing Conservation Program Manager must maintain a close collaborative relationship with command leadership and Safety Managers of supported noise hazard commands, in addition to MTF Industrial Hygiene and Occupational Medicine professionals. Effective program management requires the following:

a. Work Schedule. OA’s will allocate no more than 50 percent of the OA work schedule toward patient care to enable the proper distribution of efforts toward the primary mission of hearing loss prevention. Patient care responsibilities include:

(1) Reviewing referrals and determining disposition.

(2) Providing comprehensive diagnostic audiology care and services to referred patients.

(3) Conducting medical qualification assessments on HCP enrollees that meet criteria for further audiological and fitness for duty evaluation.

b. At least 50 percent of the work schedule must be allocated to hearing loss prevention outreach efforts, program oversight, and management functions. OAs must maintain objective tracking documentation on how this time is spent. This includes:

(1) Maintaining a current, comprehensive directory of supported noise hazard commands within the MTF AOR. For each supported command and in collaboration with the

Safety Officer and Work Area Supervisor (see Sections C.13 and C.14), the following minimum documentation is maintained: Unit Identification Code (UIC), HCP enrollment numbers, estimated program compliance data, PTS/hearing injury rates, and contact information for key HCP stakeholders. The directory must be updated at least semi-annually. Collaborative partnerships with IH personnel and the ability to access noise surveys and shared files is essential for maintaining current HCP directory information.

(2) Prevention Outreach. Each full-time OA must complete a minimum of 12 documented HCP training or hearing loss prevention events per fiscal year with supported noise hazard commands. Prevention Outreach must be tracked in Excel or other effective database tracking system and kept on file for at least 5 years. The objective of these events is to provide tangible program assistance and hearing loss prevention services that yield effective outcomes and return on investment (i.e., reductions in hearing injury/risk, greater awareness of noise hazard impacts, hearing protection use/fit improvements). Prevention Outreach may include:

(a) Worksite Assessments. Worksite assessments include a walk-through of the noise hazard worksite area(s) and review/evaluation of overall program compliance, worksite noise hazards, noise hazard signs/labels, hearing protection options/availability, employee communication requirements/challenges, potential for engineering controls/noise hazard reduction, and providing professional expertise and consultation on hearing loss prevention and HCP improvement initiatives. A worksite assessment report is sent to the command leadership/Safety Manager upon completion.

(b) Risk-Based Intervention/Support. Conducting more detailed, customized, targeted hearing loss prevention initiatives by prioritizing assistance to commands with the highest hearing injury rates, and assessing possible worksite elements, work practices and employee habits that influence injury risk. Working collaboratively with Safety, IH and other professionals to implement processes/procedures that mitigate risk.

(c) Conducting group HCP education or other substantial knowledge-based interactive hearing loss prevention activities for noise exposed personnel, supervisors, command leadership, or unit Safety personnel. Group training services may be captured as encounters in the

Electronic Health Record.

(d) Providing group consultation on hearing protective device (HPD) selection, including advanced or custom protection options, or conducting HPD fit check assessments. HPD fittings and Fit-Check services must be captured as encounters in the Electronic Health Record.

(e) Base Safety Council meetings. Providing/presenting HCP information and statistics, such as: noise hazard command program performance data (estimated compliance, hearing injury/PTS), HPD options/samples/fitting demonstrations/new technology, HCP Self-

Assessment checklist items, literature on available HCP services, and OA/HCP contact information.

(f) Networking/Relationship building. Maintain monthly email communications with 100% of noise hazard command safety managers and officers in the AOR. Establish systematic contact and on-site collaborative meetings with noise hazard command Safety Managers in the AOR to develop proactive communication and facilitate reciprocal cooperative relationships in the prevention of occupational hearing loss.

(3) Clinic Assist Visits. OAs who provide oversight to multiple HCP points of service locations must visit and assess each site quarterly. Clinics outside a 120 mile radius must be visited at least annually. An After Action Report is provided to the clinic Officer-in-Charge (OIC).

Technician refresher training is encouraged during visits. See the NMCPHC website for Clinic

Assist Visit checklist. Infection control protocol will be reviewed as part of the Clinic Assist Visit.

See the NMCPHC website for infection control guidance.

(4) Hearing Conservation Technician Certification Courses. Periodic standardized hearing conservation technician certification courses are conducted to maintain adequate staffing and credentialing of certified technicians in the AOR. Course frequency is commensurate with local demands. OAs must maintain current hearing conservation Course Director credentials through CAOHC. See section II.C.2.e under Responsibilities for guidance on conducting HCT

Certification Courses.

(5) Annual Technician Competency Evaluations. The provision of audiometry and other hearing conservation support services is accomplished under the supervision of an audiologist, otolaryngologist, occupational medicine physician, or other qualified physician. Technician proficiency in audiometric test instructions, administration, patient education, and HPD fittings is evaluated and documented at least annually as part of the certification maintenance process using the standardized form that can be found on the NMCPHC website. Technician Competency

Evaluations are completed on all active certified technicians in the AOR. Active technicians are those who have administered audiograms within 1 year. Newly certified technicians are considered fully qualified and a competency evaluation is not required until 1 year from certification date.

(6) Hearing injury notification reports. Formal notification is provided to the patient and his/her supervisor within 21 days of OA confirmation of a work-related PTS or OSHA recordable hearing loss. A sample report is located on the NMCPHC website.

(7) HCP Performance Reports. Annual fiscal year HCP performance reports are provided to supported commands, and must include estimated compliance and PTS/hearing injury rates. The NMCPHC website provides a template for the HCP Performance Report.

c. Audiology Equipment. The MTF or regional OA must be involved in all audiology equipment purchases and installations. Prior to submitting a procurement package, consult the cognizant Regional HCPM on all audiometric test booth purchases for review. See section V for a listing of current standard of care audiology equipment.

d. Peer Review. OAs will complete peer review process in accordance with local command credentials protocol. In the absence of a qualified Occupational Audiologist to provide peer review services, the Regional Audiologist will assist with coordinating a viable peer review process.

8. Hearing Conservation Technician (HCT).

a. Educates HCP enrollees on the components, requirements, and benefits of the HCP.

b. Reviews ear and hearing information from patient’s medical record. Obtains patient history on conditions that may contribute to loss of hearing sensitivity, or that may affect hearing test results. Documents any significant patient history in the medical record.

c. Performs otoscopic examination of ear canals to ensure there are no medical contraindications to testing, such as excessive ear wax, foreign bodies, evidence of infection or disease or other conditions that may affect hearing or the insertion of earplugs. When contraindications to testing are noted, the HCT refers the employee to appropriate provider for evaluation, treatment and disposition.

d. Prepares patients for hearing tests. Gives clear, concise test instructions. Administers air conduction audiometric tests. For HCP enrolled patients, compares annual hearing test results to the most current Reference Audiogram (DD Form 2215) in the patient’s medical record to determine if a Significant Threshold Shift (STS) exists. Reviews audiogram results with patients.

Enters test results in the patient’s medical record.

e. Schedules and performs follow-up tests, tympanometry, Hearing Protection Device

(HPD) checks/fittings, or other procedures, as required. Refers patients with STS on final follow-up test to Occupational Audiology. Consults with OA on referral and disposition of patients with asymmetrical hearing loss, low frequency loss or unusual/abnormal test results. Adheres to referral guidelines outlined in section V.

f. Ensures fit of issued HPDs, demonstrates proper use and discusses advantages, limitations, and possible consequences of misuse or non-use. Educates on proper care and maintenance of hearing protective devices. Determines special hearing protective needs based on patient needs, concerns and work environment.

g. Ensures proper maintenance of audiometric equipment. Prior to daily patient testing, performs a functional and a biological calibration check of the equipment. Records results on a DD

Form 2217, or stores results in microprocessor. Follows infection control guidelines found on the

NMCPHC website for cleaning patient headphones and patient exam areas.

h. Electronically transmits hearing conservation test result data to the DOEHRS DR daily.

Prepares and submits other hearing conservation reports as needed or as requested by Occupational

Audiology.

9. NEPMU Audiologist. Provides HCP oversight and consultation to supported operational platforms.

a. Conducts shipboard Technical Assist Visits for specified commands (in accordance with local agreements) to monitor HCP compliance and provide trend analysis.

b. Supports readiness for fleet safety and medical inspection requirements, such as the

Board of Inspection and Survey (INSURV), Naval Safety Center Survey, Medical Readiness

Inspection, and Afloat Training Group Inspection.

c. Conducts annual HCT Competency Evaluations for shipboard HCTs with specified commands.

d. Provides support to remote active duty service members receiving HCP audiograms outside of the MTF. Support includes reviewing these audiograms, inputting the audiograms into

DOERHS-HC, and recommending follow-up testing as needed.

10. Clinical Audiologist. Provides auditory and vestibular diagnostic evaluations, aural rehabilitation, hearing aid fittings, disposition, medical record documentation, and appropriate tertiary care referral(s).

11. Industrial Hygiene (IH): Responsible for conducting noise exposure assessments and designating noise hazardous areas and equipment based on the noise measurements and associated information as part of IH surveillance programs. Industrial Hygienists provide HPD recommendations and employee HCP enrollment recommendations based on the noise exposure assessments. Exposure assessment results, along with the associated recommendations, are submitted to customer commands via a baseline, periodic or special IH survey report. Industrial

Hygienists typically conduct ashore and afloat annual audiometric test booth certifications. Upon request, IHs may participate as instructors in Hearing Conservation Technician Certification courses. Additional information pertaining to noise exposure assessments and the role of Industrial

Hygienists is provided in Chapter 5 of the NMCPHC, Industrial Hygienist Field Operations

Manuali.

12. Occupational Medicine (OM). OM professionals (to include OM Providers and

Occupational Health Nurses) have training and experience with the HCP and can be of assistance with program implementation and guidance. Their scope of responsibilities include:

documentation of employee occupational health histories, medical surveillance assessments, medical certifications for select occupations, worksite visits, review and analysis of IH data, identification of appropriate employee work restrictions, and occupational Fitness for Duty evaluations on military and federal civilian workers.

13. Safety Officer. The Commanding Officer has overall responsibility for the HCP. The

Safety Officer and Work Area Supervisor manage and track program implementation and compliance. The Safety Officer is responsible for establishing and maintaining the roster of HCP enrolled personnel and semi-annually providing the cognizant medical facility with the total program enrollment number. The Safety Officer is also responsible for tracking and recording PTS hearing injury and OSHA recordable hearing loss through an established electronic mechanism, such as Web-Enabled Safety System (WESS), Enterprise Safety and Management System

(ESAMS) or MRRS. The Safety Officer is responsible for exploring engineering and administrative noise abatement controls.

14. Work Area Supervisor. Work Area Supervisors are responsible for tracking HCP enrollment, enrolling and removing personnel from the HCP based on noise exposures and IH survey recommendations, and managing and tracking medical surveillance exams for their assigned personnel. Specific to the HCP, Work Area Supervisors must ensure medical surveillance compliance is met by coordinating appointments with the supporting MTF, using SECNAV 5100/1

(found on NMCPHC website) form for communicating the type of assessments needed from the

MTF, and ensuring personnel complete required appointments. Work Area Supervisors are responsible for ensuring effective HPDs are available to personnel and that their employees properly wear HPDs in noise hazardous areas/conditions. Work Area Supervisors will notify the

Safety Officer and/or request a noise survey whenever a change in operations may impact noise levels.

III. Noise Measurement and Control

A. Reference (i) Chapter 5 (Noise Surveys) provides guidance on:

Noise Measurement and Evaluation (IH Surveys)

Noise Exposure Monitoring Plans

Identifying and Labeling Hazardous Noise Areas and Equipment

Audiometric Booth Certification

B. Noise Abatement and Control. Engineering controls constitutes the primary method for preventing occupational hearing loss. Removing or reducing hazardous noise from the source is the most effective method for preventing occupational hearing loss and creating a safe sound environment. Every effort must be made to eliminate or reduce identified noise hazards through the systems engineering and systems safety process. Industrial Hygienists, Occupational Audiologists, command leaders, Facilities Managers and Safety Managers collaborate on appropriate engineering controls and apply processes for eliminating or reducing the noise, where possible.

1. Administrative control of exposure time is required in cases where noise control is not possible and hearing protective devices provide insufficient attenuation to reduce the employee’s effective exposure level below 85 dBA Time Weighted Average (TWA). Implementation of administrative controls must be accomplished under strict supervisory control, and in consultation with safety and industrial hygiene or occupational audiology.

2. If hazardous noise exposure cannot be sufficiently eliminated or reduced through engineering and administrative controls, appropriate HPDs should be fitted for each individual exposed.

C. HCP Enrollment. Military and civilian personnel working in hazardous noise areas will be identified by their parent activity and enrolled in the HCP. Subsequently, these employees will undergo hearing protection fitting and issue, annual hearing loss prevention education, and annual audiometric testing. Per reference (f) all active duty and reserve U.S. Marine Corps personnel are enrolled in the HCP. Civilian personnel should not be HCP enrolled if there is documented evidence that they do not meet enrollment criteria, as this introduces potential for unwarranted liability and compensation claims, and adds undue burden onto government and medical systems.

D. HCP Enrollment Criteria.

1. Noise hazard exposure criteria that requires enrollment in the HCP:

a. >85 dBA TWA continuous and intermittent noise for 1 day or more per year. TWA calculation is based on an 8 hour workday with a 3 dB exchange rate.

b. >140 dBP SPL impulse noise for 1 day or more per year.

2. Exposure assessments should be made to determine hazardous noise areas and operations.

Assessments include noise measurements performed per reference (i), which will determine personnel enrollment in the HCP per reference (e). Assessments should be made initially and reassessed whenever operations have changed based on the risk management process of DoDI

6055.05 per reference (c). In addition, noise surveys should be performed when a ship has undergone a major repair availability, had significant work to existing engineering systems, or has new equipment installed per reference (e). Acquisition and new system development should incorporate noise measurements during the test and evaluation stage per reference (d). When insufficient noise data is available to determine risk, personnel may be enrolled in the HCP based on the sampling of Similarly Exposed Groups (SEGs).

3. Per reference (f), all active duty and reserve U.S. Marine Corps personnel, and all active duty and reserve Navy personnel serving with or supporting USMC units are enrolled in the HCP, regardless of noise exposure levels. All civilian personnel occupationally exposed to hazardous noise will be enrolled in the HCP according to the criteria listed under section III.D.1 above.

E. HCP Enrollment Responsibilities/Actions.

1. Medical Department Industrial Hygiene personnel are responsible for identifying noise hazardous areas and equipment within a command during baseline and periodic noise hazard surveys and during select noise exposure monitoring events. Formal IH survey reports are subsequently provided to commands detailing the noise hazard areas and operations.

2. Commands are responsible for identifying the personnel who work in noise hazard areas or operations, enrollment of personnel into the HCP, removing personnel from the HCP when they no longer work in hazardous noise, and semi-annually updating HCP enrollment rosters/databases.

3. Visitors to hazardous noise areas are required to wear hearing protection, but are not required to be enrolled in the HCP, have their hearing tested or be included on a roster of noise exposed personnel.

F. Questions regarding the health effects of unusual noise exposures should be directed to an

Occupational Audiologist, Occupational Medicine Physician, or NMCPHC. Such exposures may include, but are not limited to, the following:

Greater than 16 hours of continuous or intermittent exposure per day

Intense low frequency noise (i.e., when the difference between the C-weighted and A-weighted values are greater than 15 dB)

High intensity noise above 140 dBA sound pressure level

Impulse/impact noise above 165 dBP sound pressure level

Facility/equipment alteration that significantly impacts noise levels

IV. Hearing Protection

A. Hearing Protection Device (HPD) Use. HPD use is mandatory when personnel are occupationally exposed to noise levels of >85 dBA or >140 dBP. HPDs and earplug carrying cases are provided to and worn by personnel working in potentially hazardous noise in accordance with appendix B references (d) or (e). Areas or equipment where the sound pressure levels are 104 dBA or greater or 165 dB peak or greater shall be labeled and require the use of double hearing protection (earplugs and circumaural muffs). Personnel who are not in compliance with the mandatory and appropriate use of hearing protection in noise-hazardous areas (double protection where required) are subject to administrative or disciplinary action. Per Appendix B references (d) and (e), all personnel exposed to weapons fire regardless of a simulated or live training event must wear HPDs. Commanders will determine the use of HPDs in combat based on mission requirements, the impact on communication, and situational awareness per appendix B references

(d) and (e).

B. Hearing Protection Product Selection. Commercial HPD product Noise Reduction Rating

(NRR) values are not representative of real world attenuation. Reference (i) describes calculation methods for determining more authentic product noise reduction capability to help facilitate appropriate HPD selection. HPD attenuation measurements conducted by government labs (and government approved labs) reflect accurate noise reduction values and can be relied on when selecting HPD devices. Noise hazard commands are advised to consult with MTF Occupational

Audiologists or Industrial Hygienists on product selection to assure that selected devices are appropriate and effective for the noise environments. Field attenuation estimation systems, commonly referred to as a fit-test system are recommended as a best practice. Field attenuation estimation using the fit-test system should be performed by a trained safety professional or industrial hygienist per reference (d), or by an occupational audiologist.

1. Considerations for hearing protection are found on the NMCPHC website.

2. Information and guidance on NRR, ordering information, custom molded hearing protection and other HPD products is available on the NMCPHC website.

3. The user should be permitted some freedom of choice in the selection of hearing protective device type, unless the selected protector is medically contraindicated or inappropriate for a particular noise hazardous area or operation. Pre-formed and hand-formed earplugs, as well as other HPD options should be available at all times for personnel in the Hearing Conservation

Program, and hand-formed disposable earplugs must be available for visitors to noise-hazardous areas.

4. OA consultation is recommended in instances of HCP enrollee significant hearing loss, high intensity noise exposures (TWA’s in excess of 104 dBA or 165 dBP impulse/impact), Fitness for Duty (FFD) concerns, or communication-critical situations.

C. Specialized Hearing Protection Products and Communication Devices.

1. Use of custom hearing protection devices is authorized. HCP enrolled personnel have the option to use custom hearing protection to effectively reduce excessive noise exposure and maintain and/or enhance communication ability. Only audiologists, otolaryngologists, or trained aviation physiologists/technicians may take impressions of the ear necessary to make the custom earplugs.

Consult local audiologist for custom ear impression guidance and protocols.

2. Procurement of Tactical Communication and Protection Systems (TCAPS), or other advanced electronic devices that enhance or improve communication and reduce noise exposure should be coordinated with the MTF Occupational Audiologist, who can provide product selection advice, device fitting, training support, and attenuation assessments.

D. HPD Fitting Procedures.

1. While the command or activity is required to purchase, provide and maintain hearing protection for its employees, non-disposable and specialized hearing protectors require accurate sizing and fitting by medically trained personnel. Before any such device is placed in an ear, a well-lighted visual inspection is necessary to determine whether any condition is present that would make insertion inadvisable, such as, observable pathology or excessive earwax. Each ear canal will be inspected and sized separately.

2. HPD fit is a critical factor in preventing Noise-Induced Hearing Loss. The quality of the fit significantly influences the amount of protection provided by the device. Provision of personal hearing protection of any sort requires basic instruction as to use and care. All personnel required to wear hearing protection will receive adequate and effective training in the proper use and care of hearing protective devices. Medically trained personnel must examine the fit and condition of preformed, specialized and custom earplugs at initial fitting and at least annually, preferably in conjunction with the annual hearing test.

3. Recreational listening devices must not be used in place of or in conjunction with approved hearing protectors. Hearing aids or amplification devices must not be used in noise hazard areas, unless specifically approved by an audiologist. Hearing aids must not be used in place of or in conjunction with an approved hearing protector unless approved for that purpose by an audiologist.

Any decisions to waive or alter the use of HPDs must be made and documented by an occupational audiologist.

E. HPD Purchase and Procurement. As with all personal protective equipment, purchase and provision of hearing protection and communication devices is a responsibility of noise hazard commands. Hearing protection and earplug carrying cases are considered safety supply items, not medical items. MTF’s must also maintain a supply of a variety of HPDs and carrying cases for the purposes of educating command safety representatives, employee supervisors, and employees on available and appropriate HPD options and current technology.

V. Audiometric Monitoring

A. Audiometric Testing and Diagnostic Audiology Services. The Navy Medical Department is responsible for the provision of all required HCP evaluations to include diagnostic audiology evaluations and Medical Qualification/Auditory Fitness for Duty (AFFD) evaluations. All hearing evaluation results must be captured and maintained in the Electronic Health Record. On joint service and sister service bases, medical surveillance and diagnostic hearing evaluations may be obtained through certified technicians and audiologists from supporting DoD MTFs via MOA.

Navy and DoD occupational audiologists are the subject matter experts on federal regulations and military guidance regarding occupational hearing standards and requirements for AFFD determination.

B. Audiometric Equipment and Software Requirements. Audiology equipment must be replaced once it has exceeded its life cycle expectancy.

1. For HCP Medical Surveillance Audiometric Testing:

a. Certified audiometric test chamber (audio booth)

b. Benson Medical CCA-200 mini microprocessor audiometer for each station with accompanying headphones and patient response button (provided by NMCPHC)

c. Benson Medical BAS-200 Acoustic Simulator for each station (provided by NMCPHC)

d. Current version of DOEHRS-HC software

e. Otoscope

f. Middle ear screener (optional/recommended)

g. Otoacoustic Emission Screening equipment (optional/recommended)

2. For diagnostic audiology assessments:

a. Certified audiometric chamber that meets diagnostic test attenuation requirements

(recommend double-walled booth)

b. Enterprise Clinical Audiology Application (ECAA)-compatible diagnostic audiometer with accompanying headphones, bone oscillator and patient response button

c. ECAA-compatible middle ear analyzer

d. Otoacoustic Emission equipment

e. Diagnostic otoscope

f. Compact disc player/device for administering recorded speech tests

g. Hearing Protection Fit-Check equipment

h. Custom earmold impression equipment and supplies

i. Current version of ECAA software

j. Virtual Audiology Equipment (optional/recommended for supporting remote clinics)

3. Audiology Booth Installation and Certification Requirements.

a. Audiometric test chambers (audio booths) must be certified annually with a Type 1

Octave Band Analyzer (OBA) meter with a 1 inch microphone, meeting the requirements of the most recent version of ANSI standards. Recertification is also required when a chamber, including

Mobile Occupational Hearing Conservation Audiometric Truck (MOHCAT), is relocated, and whenever there is a significant change in ambient noise levels that could affect hearing testing.

b. Certification is performed by an industrial hygienist, audiologist, or others meeting guidelines established by NMCPHC. An approved booth certification form with instructions for conducting a booth certification is provided on the NMCPHC website. Current booth certifications must be posted in the area where audiometric testing is performed.

c. New booth purchases or relocation of existing booths must be coordinated through the local Audiologist. The regional OA must be consulted to ensure the appropriate size and type of booth is selected. Adequate space planning and preparation is required when determining facility location for audiometric testing services. Sound-treated audiometric chambers occupy a significantly large footprint. The designated room must also accommodate audiometric medical equipment, office furniture, and patient counseling area. Sound attenuation is critical for obtaining valid audiometric results, therefore, careful pre-planning is required prior to booth purchase and installation. Audiometric testing locations should be designated in areas away from known noise sources, such as conference rooms, break rooms, auditoriums, ambulance bays and other significant outdoor noise sources, intercom systems, ventilation systems, and heavy patient traffic areas.

4. Equipment Use, Maintenance and Calibration Requirements.

a. Medical Surveillance Audiometric Equipment. All MTF hearing conservation audiometric testing sites must use the DoD designated microprocessor audiometer with the most recent version of the DOEHRS-HC software for all hearing conservation testing.