Evaluation form of a suspected hearing loss
Victim _______________________ Rank ______________ Arrival date to FDF ______________
Shooting Director______________ Shooting date ____________
Weapon	Assault rifle	□	Mortar	□
	Pistol	□	Cannon	□
	Machine gun	□	Missile	□
	Bazooka	□		□	Other __________________
Cartridge	Blank	□	Hard	□	Other __________________
Shooter	Himself/herself	□		□	Other __________________
Distance from the weapon	<2 m	□	2–5 m	□
	5–10 m	□	>10 m	□
Hearing protection	Ordered to use	□	No	□	why ___________________
Use of the hearing protector	Has used	□	No	□	why ___________________
	Forgotten	□
	Fallen off	□
	Accidental shot	□
	Did not have time	□
	Not delivered	□
	Other ____________________
Protector type	Ear plug	□	Muff and plug	□
	Muff	□	Communication headset	□
Training for its use	Well trained	□	Not sufficiently trained	□
	Sufficient practice	□	Not sufficiently practiced	□
Description of the incident
Signatures; Conscript, chief of the military unit and medical officer