Form Approved OMB No. XXX Exp. Date
XX/XX/XXXX
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).
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 |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | King, Bradley (CDC/NIOSH/WSD) |
File Modified | 0000-00-00 |
File Created | 2023-08-31 |