3M COMBAT EAR PLUGS SCREENING SHEET Your Name (required) Address Home Phone Cell Phone Your Email (required) Branch of Military Rank/Duties # of Years Served in Military Did you serve in the military from 2003-2015? yesno Were you engaged in overseas training/combat during 2003-2015? yesno Did you have military issued dual-end earplugs during this time (black and yellow)? yesno Did you routinely use the earplugs during training/combat missions? yesno Do you have unilateral or bilateral hearing loss (or severe tinnitus) that began during your time in the military? yesno When did the hearing loss begin or become noticeable? Has a doctor or the VA documented the hearing loss in your medical records? yesno Did you have any hearing loss prior to serving in the military? yesno Do you have any of the following conditions that may have contributed to hearing loss? Branchiotorenal syndromeStickler syndromeUsher syndromePendred syndromeAlport syndromeOtosclerosisMeniere's diseaseNone of these Marital Status MarriedMarried with ChildrenSingleSingle with Children Is there anyone in your family or household that can verify your hearing changed while serving in the military? Are there any specific instances where you recall wearing the earplugs and they became dislodged? Are there any specific instances where the earplugs failed to adequately protect you from loud noises?
