Hearing Loss Exposure Addendum
NON-OCCUPATIONAL NOISE EXPOSURE HISTORY
Claimant's Name Claimant's Social Security Number Protection Used? Yes No
Return completed form to: American Mining Claims Service P.O. Box 660988 Birmingham, AL 35266-0988
Yes Hunting
No
How Often
Type (Plugs, Muffs or Caps)
Trap Shooting
Firing Range
Loud Music
Walkman
Weed Eater
Lawn Mower
Power Tools
Chain Saw
Skill Saw
Band Saw
Air Compressor
Heavy Equipment
Farm Machinery
Auto Mechanic
Racing
Pilot
Motorcycle
Snow Mobile
Indoor Athletics
Other
Other
MILITARY SERVICE Do you have prior military experience? Did you have a combat assignment? What was your job in the military? Noise exposure other than basic training? Military Address / Location Service From To Job Description Type of Machinery / Equipment Used Exposure to Noise Hours / Days Hearing Protection Worn? Yes Yes No No If yes, which branch? If yes, how long? How many weeks of basic training?
Comments?