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entitled 'Hearing Loss Prevention: Improvements to DOD Hearing 
Conservation Programs Could Lead to Better Outcomes' which was 
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United States Government Accountability Office: 

Report to Congressional Committees: 

January 2011: 

Hearing Loss Prevention: 

Improvements to DOD Hearing Conservation Programs Could Lead to Better 


GAO Highlights: 

Highlights of GAO-11-114, a report to congressional committees. 

Why GAO Did This Study: 

Exposure to hazardous noise can have negative implications for both 
servicemember health and readiness. Moreover, in fiscal year 2009, 
some of the most common impairments for veterans receiving Veterans 
Affairs (VA) disability benefits were hearing related, as annual 
payments for such conditions exceeded $1.1 billion. To examine 
Department of Defense (DOD) efforts to prevent hearing loss, GAO is 
reporting on (1) how well the DOD and armed services identify and 
mitigate hazardous noise; (2) how well the military evaluates hearing 
conservation program performance; and (3) the status of DOD’s Hearing 
Center of Excellence and the extent that DOD and VA are sharing 
information to inform this and other efforts. GAO reviewed DOD and 
services’ policies and guidance, reviewed DOD performance data, 
interviewed officials and servicemembers, and conducted site visits to 
nine military bases. 

What GAO Found: 

Each of the armed services is taking steps to monitor hazardous noise, 
but inconsistencies in some hearing protection strategies and limited 
training weaken mitigation efforts. Services monitor noise 
periodically, depending on the level of risk servicemembers have in 
being exposed to hazardous noise (for example, annually for firing 
ranges and flight decks, and every 5 years for administrative 
offices). However, they lack a reliable system for detecting changes 
in noise levels that may occur outside the scheduled review cycle. 
Although DOD requires that noise be controlled by setting exposure 
limits and requiring the use of hearing protection, these strategies 
are not consistently used. For example, servicemembers told us that 
they do not always wear hearing protection, citing concerns with 
comfort and communication. Annual hearing-related training is required 
for at-risk servicemembers, but services are not able to fully 
determine who has completed annual training, and many servicemembers 
told GAO that training is not necessarily well timed. 

DOD’s evaluation of services’ hearing conservation programs has key 
weaknesses, but some services have taken steps to review and improve 
their own programs. First, DOD performance indicators are not 
sufficiently comprehensive. One key indicator--the rate of hearing 
loss among servicemembers in the hearing conservation programs—-only 
measures program performance after hearing loss has occurred. Second, 
evaluation is limited by weaknesses in the processes used to capture, 
track, and use performance data. For example, the data may not 
accurately capture the number of servicemembers enrolled in the 
respective programs—a number required to calculate compliance rate. 
Third, audiologists, and other key stakeholders do not, on some bases 
GAO visited, routinely coordinate to share and evaluate hearing loss 
data to identify and mitigate noise hazards. Individual services have, 
at times, conducted reviews of their own programs and made some 
improvements. For example, once the Army decided that soldiers would 
not be deployed if the individual had not completed a required hearing 
test, the number of hearing tests rose significantly. 

DOD has developed, though not yet finalized, a plan for a Hearing 
Center of Excellence to improve hearing loss prevention and treatment 
as well as a plan for its registry to track and share information with 
VA on injured military personnel and veterans. Neither Congress nor 
the DOD set a date for when planning should be formally approved to 
implement the center, but a key DOD official estimated that plans may 
receive final DOD approval in the near future. In the meantime, an 
interim director for the center has begun to lay the groundwork for 
implementation of both the center and the registry. While data sharing 
between DOD and VA has been very limited to date, military and VA 
officials said the registry should ultimately facilitate sharing and 
development of best practices. 

What GAO Recommends: 

GAO recommends that to improve hearing conservation programs, DOD 
should address issues with the type, timing, and tracking of training 
and education; develop an appropriate set of performance indicators; 
improve processes to collect and use performance data; and examine 
services’ reviews to identify opportunities for program improvement. 
In reviewing a draft of this report, DOD concurred with GAO’s 
recommendations. DOD and VA provided technical comments, which GAO 
incorporated as appropriate. 

View [hyperlink,] or key 
components. For more information, contact Daniel Bertoni at (202) 512-
7215 or 

[End of section] 




Services Are Employing Strategies to Identify and Mitigate Hazardous 
Noise, but Inconsistent Practices and Limited Training Weaken Their 

DOD's Approach to Evaluating Hearing Conservation Has Key Weaknesses, 
While Some Services Have Taken Steps to Review and Improve Their Own 

Plans Are Almost Complete for Both the Hearing Center of Excellence 
and a System to Facilitate DOD and VA Data Sharing: 


Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Comments from the Department of Defense: 

Appendix III: GAO Contact and Staff Acknowledgments: 


Table 1: Key Elements of DOD Hearing Conservation Programs: 

Table 2: Military Bases Visited during GAO Review of Hearing 
Conservation Programs: 


Figure 1: Growth in Numbers of New VA Disability Compensation Awards 
to Veterans for Hearing Loss and Tinnitus for Fiscal Years 2005 
through 2009: 

Figure 2: Example of a Noise Dosimeter and Sound Level Meter: 

Figure 3: Examples of Hearing Protection Devices: 

Figure 4: Example of a Hazardous Noise Sign That Does Not Include the 
Level of Hearing Protection Equipment Needed: 

Figure 5: Example of the Proximity of Flight Line Personnel to 
Military Aircraft: 


AFCESA: Air Force Civil Engineering Support Agency: 

DOD: Department of Defense: 

DOEHRS: Defense Occupational and Environmental Health Readiness System: 

HCP: hearing conservation program: 

IOM: Institute of Medicine: 

NAS: Naval Audit Service: 

OSHA: Occupational Safety and Health Administration: 

STS: significant threshold shift: 

VA: U.S. Department of Veterans Affairs: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

January 31, 2011: 

The Honorable Carl Levin: 
The Honorable John McCain: 
Ranking Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Howard P. "Buck" McKeon: Chairman: 
The Honorable Adam Smith: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

Military service can expose soldiers to hazardous levels of noise, 
ranging from gunfire to military aircraft, all of which can lead to a 
loss or damage in hearing if protective equipment and measures to 
reduce exposure are not employed in advance. Well before retirement, 
such damage can reduce servicemembers' ability to communicate and 
affect the quality of their professional and personal lives. Moreover, 
it can create additional costs to the government and taxpayers by 
decreasing troop readiness and increasing the need for medical 
services and disability compensation. To protect servicemembers' 
hearing, the Department of Defense (DOD) and the armed services have 
established hearing conservation policies and programs. Nevertheless, 
U.S. Department of Veterans Affairs (VA) has reported that tinnitus 
(ringing in the ears) and hearing loss remain some of the most common 
service-connected disabilities. Approximately $1.1 billion in 
disability compensation was paid out for these two conditions in 
fiscal year 2009. 

Many have raised concerns about the need to protect servicemembers' 
hearing, including DOD, VA, Congress, and national organizations 
dedicated to protecting hearing. Such concern on hearing-related 
disabilities prompted Congress in October 2008 to require that DOD 
establish a center dedicated to the prevention and rehabilitation of 
servicemembers and veterans with auditory disabilities. Congress has 
mandated GAO to review DOD's hearing protection efforts and report on 
the status of the hearing center.[Footnote 1] Specifically, to respond 
to this mandate and gain insight into DOD's efforts to prevent hearing 
loss, we determined (1) how well the DOD and armed services identify 
and mitigate hazardous noise; (2) how well the military evaluates 
hearing conservation program performance; and (3) the status of DOD's 
Hearing Center of Excellence and the extent to which DOD and VA are 
sharing information to inform this undertaking and generally protect 
servicemembers. To address objectives one and two, we reviewed DOD and 
armed services hearing conservation policies and guidance, reviewed 
other federal agencies that set standards and policy for hearing 
conservation, and interviewed cognizant military officers from DOD, 
Army, Navy, Air Force, and Marines, as well as stakeholders. We 
reviewed past evaluations of DOD hearing conservation programs, 
including a study conducted by the Institute of Medicine (IOM). We 
conducted site visits to nine military installations. During these 
site visits, we interviewed senior officials, audiologists, industrial 
hygienists, servicemembers, safety officers, and other officials who 
assess, measure, and mitigate occupational health hazards. We selected 
these site visits based on a number of factors, including the military 
branch, size of the installation, presence of different types of 
hazardous noise, and geographic location. To determine how DOD and the 
armed services monitor program performance, we also interviewed 
cognizant officials, reviewed hearing conservation performance 
measures and program data and reviewed documentation for DOD's Defense 
Occupational and Environmental Health Readiness System (DOEHRS), and 
analyzed key system reports for each of the armed services. To address 
objective three, we interviewed the DOD Hearing Center of Excellence 
program manager, the interim director of the Hearing Center of 
Excellence, as well as representatives from the VA involved with the 
center's development. 

We conducted our overall performance audit from November 2009 to 
January 2011 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient and appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. For 
additional information on our scope and methodology, see appendix I. 


Noise is one of the most common occupational health hazards faced by 
military servicemembers. Servicemembers may be exposed to high- 
intensity noise of various types during their training and when 
performing general job duties or combat operations. Without proper 
protection, this exposure can cause or contribute to tinnitus and 
hearing loss. The effects of tinnitus, a ringing in the ears 
significantly associated with unprotected exposure to hazardous noise 
and noise-induced hearing loss, can range from minor to debilitating 
and can be permanent. Noise-induced hearing loss, and occasionally 
tinnitus, can be rehabilitated with a hearing aid, but they are 
permanent disabilities. 

After leaving the military, servicemembers who sustain tinnitus or 
hearing loss during service may qualify for compensation from the VA. 
VA's disability compensation program compensates veterans for the 
average loss in civilian earning capacity that results from injuries 
or diseases incurred or aggravated during military service, regardless 
of current employment status or income. In fiscal year 2009, VA 
compensated 1.2 million claims for veterans with either tinnitus or 
hearing loss injuries,[Footnote 2] representing an annual federal 
expenditure exceeding $1.1 billion for disability compensation 
payments.[Footnote 3] In 2005, auditory impairments, which include 
hearing loss and tinnitus, became the most common service-connected 
disabilities compensated by VA. Since 2005, VA has reported that the 
numbers of veterans who have begun receiving compensation each year 
for these disabilities have continued to grow, contributing to VA's 
increasing annual expenditure on disability claims (see figure 1). 

Figure 1: Growth in Numbers of New VA Disability Compensation Awards 
to Veterans for Hearing Loss and Tinnitus for Fiscal Years 2005 
through 2009: 

[Refer to PDF for image: multiple line graph] 

Number of awards for service-connected disabilities: 

Year: 2005: 46,739; 
Year: 2006: 51,360; 
Year: 2007: 62,488; 
Year: 2008: 67,689; 
Year: 2009: 77,486. 

Hearing loss: 
Year: 2005: 38,657; 
Year: 2006: 38,330; 
Year: 2007: 46,591; 
Year: 2008: 47,733; 
Year: 2009: 54,450. 

Source: Veterans Benefit Administration annual benefits reports, 
fiscal years 2005 through 2009. 

[End of figure] 

Beyond the cash benefits VA provides to veterans with hearing-related 
disabilities, there are other expenditures by both VA and DOD to 
rehabilitate, treat, or correct auditory injuries. For example, VA 
purchased almost 382,000 hearing assistive devices in fiscal year 
2008, for an expenditure of approximately $154 million.[Footnote 4] 

Both noise-induced hearing loss and noise-induced tinnitus may be 
avoided through auditory injury prevention, referred to as hearing 
conservation. Due to the introduction of the jet engine to military 
environments and the number of World War II veterans who sustained 
hearing loss during combat, hearing conservation became a concern of 
the armed services in the late 1940s. According to a recent IOM study, 
in 1948, the armed services began developing hearing conservation 
programs and, in 1978, DOD issued the first departmentwide hearing 
conservation directive that provided guidelines to unify the 
implementation and goals of hearing conservation programs (HCP) 
throughout the armed services.[Footnote 5] 

According to DOD policy, the goal of hearing conservation is to 
protect all servicemembers and other personnel from hearing loss 
resulting from occupational noise exposure. The policy states that 
each armed service is to implement a hearing conservation program, 
including the Air Force, the Army, the Marine Corps, and the Navy, and 
that these programs are to be implemented when personnel are exposed 
to a certain level of noise.[Footnote 6] All the services have 
policies that include the enrollment of personnel working in areas 
with noise at or above levels that can be hazardous when performing 
their general job duties. Though military operations are not subject 
to federal civilian health and safety regulations, DOD's hearing 
conservation instructions direct that the armed services' HCPs comply 
with federal standards whenever practicable.[Footnote 7] 

DOD policy incorporates the following key elements into its hearing 
conservation programs: noise hazard identification, safety signs and 
labels, noise mitigation, education and training, audiometric 
surveillance, and program evaluation (see table 1).[Footnote 8] Each 
armed service branch must submit a written plan to DOD that outlines 
its program, including the strategies for implementing these elements. 

Table 1: Key Elements of DOD Hearing Conservation Programs: 

Element: Noise hazard identification; 
Purpose: Measure noise levels in all potentially hazardous noise work 
areas, evaluate and prioritize the risk in those areas, and keep an 
inventory of hazardous noise areas. 

Element: Safety signs and labels; 
Purpose: Use signs to identify entrances to and boundaries of 
hazardous noise areas and labels to designate equipment that can 
produce hazardous noise. 

Element: Noise mitigation; 
Purpose: Eliminate exposure to hazardous noise by implementing 
engineering and administrative controls and by providing and requiring 
the use of hearing protection devices. 

Element: Education and training; 
Purpose: Inform personnel of the effects of noise on hearing, the 
ability of hearing protectors to reduce exposure to noise, the purpose 
of hearing protection, the purpose of audiometric testing, the proper 
use of hearing protection and the actions to be taken for failure to 
wear the hearing protection. 

Element: Audiometric surveillance; 
Purpose: Evaluate hearing levels of personnel through audiometric 
testing and maintain records of all audiometric testing in a hearing 
conservation database and in the individual's health record, along 
with noise exposure information. 

Element: Program evaluation; 
Purpose: Use the information stored in the hearing conservation 
database to annually evaluate the hearing conservation program's 
effectiveness based on the percent of enrolled personnel who received 
annual audiograms and on the prevalence of significant threshold 
shifts (STS)[A]. 

Source: DOD and service-level guidance. 

[A] An STS is a change in hearing, in comparison to a baseline 
audiogram, of an average of 10 decibels or more in either ear at 2,000 
Hz, 3,000 Hz, and 4,000 Hz. 

[End of table] 

DOD instructions require services to reduce noise to safer levels, 
where possible, using three strategies: engineering controls, hearing 
protection, and administrative controls. DOD policy requires that 
engineering controls be the primary means of eliminating exposure of 
personnel to potentially hazardous noise. To implement engineering 
controls, services should design their work environment to reduce 
noise below hazardous levels and purchase equipment with the lower 
sound emissions. The use of hearing protection is considered an 
interim measure, but if services determine that engineering controls 
are not possible, DOD policy allows them to use personal hearing 
protection as a permanent measure to mitigate noise. Furthermore, if 
additional protection is needed, administrative controls, such as 
modifying work schedules or procedures should be used to limit 
exposure to hazardous noise. 

In recent years, studies have addressed hearing loss and tinnitus in 
the military. For example, in 2002, Congress directed that VA contract 
with the National Academy of Sciences to conduct a study on noise 
exposure with respect to hearing loss and tinnitus in the military. 
[Footnote 9] The National Academies' IOM study examined the sources of 
hazardous noise exposure in the military, levels of noise exposure 
necessary to cause hearing loss or tinnitus, the course of hearing 
loss following noise exposure, risk factors, and compliance by the 
military services with requirements for audiometric testing and the 
adequacy of their hearing conservation programs.[Footnote 10] The 
study found that military hearing conservation programs were not 
adequate to protect servicemembers' hearing. This conclusion was 
supported by findings that the annual audiometric testing of 
servicemembers enrolled in hearing conservation programs showed that 
10 percent to 18 percent had a significant shift in their threshold, 
which was estimated to be two to five times higher than rates 
considered appropriate in industrial hearing conservation programs. 
The study also found that the military programs may not perform the 
required annual audiometric testing on all servicemembers exposed to 
hazardous noise and that overall testing was not sufficient to 
evaluate changes in hearing associated with military service for the 
majority of servicemembers. Furthermore, while information was 
limited, the study noted that a high proportion of servicemembers 
(sometimes up to 50 percent in certain situations) may not be wearing 
hearing protection when needed. 

Additionally, in fiscal year 2008, the Marine Corps identified hearing 
loss among personnel as a risk in its annual Risk and Opportunities 
Assessment and, in following up, requested that the Naval Audit 
Service (NAS) conduct a review of its hearing conservation program. 
The objective of the NAS audit was to determine whether the management 
and implementation of the Marine Corps HCP is effective in protecting 
servicemembers' hearing.[Footnote 11] 

In response to serious auditory injuries incurred by servicemembers 
associated with Operation Iraqi Freedom and Operation Enduring 
Freedom, Congress mandated in October 2008 that DOD create a center of 
excellence in the prevention, diagnosis, mitigation, treatment, and 
rehabilitation of hearing loss and auditory system injury.[Footnote 
12] A key responsibility of the Hearing Center of Excellence is to 
create an electronic registry that tracks the diagnosis, treatment, 
and follow-up for each case of hearing loss and auditory system injury 
incurred by servicemembers on active duty. The center is required to 
inform VA when any of these servicemembers transition from the armed 
services to VA to help ensure the coordination and provision of 
auditory system rehabilitative services. 

Services Are Employing Strategies to Identify and Mitigate Hazardous 
Noise, but Inconsistent Practices and Limited Training Weaken Their 

Services Use a Risk-Based Approach to Monitor Sites for Hazardous 
Noise Levels, but Lack Reliable Notification for Interim Changes: 

According to services' policies, the services monitor noise levels at 
various sites on a periodic basis according to the level of risk these 
sites pose to servicemembers, but they do not provide guidance for a 
reliable notification system for changes to site conditions that may 
occur in the interim. DOD policy specifically requires the services to 
measure noise levels, and we found that hearing conservation personnel 
at each of the sites we visited use noise surveys to assess the level 
at which specific work and training areas are likely to expose 
servicemembers to hazardous noise. At the sites we visited, such site 
noise is subsequently monitored through periodic surveys, scheduled 
according to their respective level of risk. For example, at sites we 
visited, high-risk areas, such as firing ranges and flight decks, 
thought to pose the greatest chance of exposure to hazardous noise are 
surveyed annually. Medium risk areas, such as flight hangars and light 
industrial areas can be surveyed every 2 years; low-risk areas, such 
as administrative offices, can be surveyed up to every 5 years, 
depending on the service's policy. For example, Navy officials told us 
they conduct noise surveys every 4 years for their administrative 
offices, whereas Army officials conduct them every 5 years. 

According to the policies from most services, responsibility for 
measuring and reporting noise levels is delegated to experts in noise 
abatement, such as industrial hygienists, who employ a number of 
measuring devices, such as sound level meters and noise dosimeters, to 
determine how loud the noise is and how long servicemembers are 
exposed (see figure 2 for examples of measuring devices).[Footnote 13] 
At the sites we visited, the results of the measurements were recorded 
on noise survey forms that were used as the basis for reports that 
were sent to safety offices, individual military units, work sites and 
base leadership, depending on local base procedures. 

Figure 2: Example of a Noise Dosimeter and Sound Level Meter: 

[Refer to PDF for image: 2 photographs] 

Source: GAO. 

[End of figure] 

At the sites we visited, while the frequency at which the services 
monitor site noise depended on an initial determination of the site's 
risk level, it did not appear that changes to a site that alter its 
noise levels are always promptly and systematically reported. DOD 
policy requires that noise be measured within 30 days of any change in 
operations affecting noise levels; however, several noise abatement 
experts at the sites we visited told us they are not always informed 
of changes in noise. Instead, they more often encounter the changes in 
noise levels during a scheduled noise survey. Some of these experts 
suggested that servicemembers could be exposed to more hazardous noise 
levels for a prolonged period of time if no one informs them of 
changes to noise levels between scheduled surveys; some of which are 
conducted only once every several years. 

Services Employ Strategies to Mitigate Noise, but Some Practices Are 

In accordance with DOD policy for those in the hearing conservation 
program, the services employ a number of strategies to control the 
amount of exposure to hazardous noise. These strategies include 
engineering noise to safer levels, setting time limits on noise 
exposure, and requiring the use of protective equipment; however they 
are not consistently practiced. 

Engineering Controls: 

Mitigating noise thorough engineering controls can be carried out by 
improving noise reduction technology, building barriers to deflect 
noise, and through procurement of quieter equipment and technology. 
Under DOD policy, the services are required to use engineering 
controls as the primary means of eliminating personnel exposure to 
potentially hazardous noise. During our site visits, we observed 
examples of how the services have implemented such controls. For 
example, at an Air Force base maintenance shop we visited, we observed 
a "muff" being used to reduce the noise for a newly acquired water 
drill. At a Navy base we visited, a separate building was constructed 
apart from the maintenance shop to house a loud piece of equipment to 
reduce servicemembers' noise exposure. Services are also required to 
review equipment being considered for procurement to determine if they 
produce hazardous noise and consider methods for limiting the noise 
when technologically and economically feasible.[Footnote 14] In the 
Air Force, when designing weapons and facilities such as firing 
ranges, procurement decisions are not made at the base level, but are 
decided centrally by the Air Force Civil Engineering Support Agency 
(AFCESA). AFCESA attempts to strike a balance between operational 
effectiveness and worker protection when making procurement decisions. 
During this decision-making process, bioenvironmental engineers and 
other staff are involved in examining safety, fire, and occupational 
health issues--including hazardous noise. For example, AFCESA's 
involvement in the procurement of the new F-22 fighter jet led to 
considerations in how bases could redesign hangars to reduce the 
impact of noise from this plane. Officials from the Army Office of the 
Surgeon General said noise abatement experts are usually included in 
the procurement process for weapons systems, though not necessarily 
for non-weapon system procurements. Also several Navy officers from 
the Office of the Surgeon General told us the Navy has recently 
started to include industrial hygienists in the procurement of weapon 
systems though, to date, this has involved only one such procurement. 
Navy officials also added they are attempting to update their own 
procurement guidance to include noise abatement experts. However, at a 
number of sites we visited, several noise abatement experts told us 
they are not involved in the procurement process. 

Setting Time Limits: 

In accordance with DOD policy, all the services have established 
guidance detailing how long servicemembers can be exposed to certain 
hazardous noise levels without the use of hearing protection--also 
known as administrative controls. For example, the DOD allows 
servicemembers to be exposed to 85 decibels of noise, a more stringent 
threshold than the Occupational Safety and Health Administration 
(OSHA) considers hazardous, for up to 8 hours without the use of 
hearing protection equipment.[Footnote 15] However, according to a 
number of hearing conservation personnel, controlling the amount of 
time that servicemembers are exposed to noise is often more practical 
for military personnel who work in civilian or industrial style, non- 
military operations. By comparison, for servicemembers engaging in 
military operations, abiding by specific time limits is more difficult 
because their duties may require them to stay at their station beyond 
recommended limits. For example, hearing conservation personnel aboard 
an aircraft carrier we visited told us that personnel who work on the 
flight deck have flight operations lasting as long as 16 hours. 
Reflecting a similar point, an audiologist told us that controlling 
the amount of time Marines are exposed to hazardous noise in battle is 
unrealistic, as Marines cannot stop fighting because they have 
exceeded their allotted exposure time to noise. 

Personal Protective Equipment: 

DOD policy requires servicemembers to wear personal protective 
equipment, such as earplugs, when engineering controls are not 
sufficient to reduce noise levels.[Footnote 16] Based on our 
interviews with servicemembers and audiologists, we found that the 
services largely make such equipment available. More specifically, 
some servicemembers at the sites we visited told us they were able to 
obtain hearing protection primarily from their units or from hearing 
testing centers and from work or training areas (see figure 3 for 
examples of hearing protection devices). However, according to several 
hearing conservation personnel we spoke with, some of the services do 
not have an up-to-date list of approved equipment that units can 
choose from when purchasing hearing protection. They also said 
purchasers have little to no experience with hearing protection and we 
were told of a unit that, as a result, had purchased personal 
protective equipment without determining whether it would be 
effective. Hearing conservation personnel at one of the Army bases we 
visited recounted a story where one unit deployed using untested 
hearing protection that was later rejected. In addition, senior DOD 
officials also told us that some servicemembers bought their own 
hearing protection equipment that was below the required standards. 
Finally, we observed that servicemembers themselves are not 
necessarily using equipment provided to them or are not using the 
hearing protection equipment properly. 

Figure 3: Examples of Hearing Protection Devices: 

[Refer to PDF for image: 3 photographs] 

Source: GAO. 

[End of figure] 

To assure that the correct personal protective equipment is used, 
DOD's policy requires that all hazardous noise areas and industrial 
and military equipment have signs or labels that identify them as 
producing hazardous noise. The signs and labels are also expected to 
communicate the level of protective devices (i.e., single or double 
hearing protection) that should be worn to prevent hearing loss while 
working in or around the hazardous noise. However, at many of the 
sites we visited, we observed signs and labels indicating hazardous 
noise equipment or areas, although not all of the signs included the 
protective measures required. (See figure 4 for an example of a 
hazardous noise sign that does not include the level of hearing 
protection needed.) In some limited instances, a sign was not posted 
in an area that the safety officer guiding our walk-through noted 
should have had proper signage. 

Figure 4: Example of a Hazardous Noise Sign That Does Not Include the 
Level of Hearing Protection Equipment Needed: 

[Refer to PDF for image: photograph] 

Hazardous Noise: 
May Cause Hearing Loss. 

Hearing Protection Required: 
* During Normal Operations; 
* During Other Operation (Specify); 
* Plugs or Muffs; 
* Plugs and Muffs. 

Source: GAO. 

[End of figure] 

Also, some of the servicemembers at the sites we visited maintained 
that enforcement of the wearing of protective equipment is limited. 
These servicemembers said their superiors did not consistently check 
for equipment usage, and there is little to no discipline for members 
who are not using them. Some services also placed the responsibility 
for reminding their members about the importance of hearing protection 
with servicemembers who are often of lower rank and thus lack the 
authority to enforce adherence to the requirements. Army Hearing 
Program personnel described to us a program that assigned specific 
soldiers to disseminate information on hearing conservation issues and 
remind individuals to wear hearing protection. However, according to 
some Army Hearing Program staff these assigned soldiers were of low- 
rank with limited authority to ensure their peers and superior 
officers were educated on hearing conservation or wore appropriate 
hearing protective equipment. 

During our interviews with DOD officials and servicemembers, we heard 
that in some cases, servicemembers do not wear required hearing 
protection. During our site visits, many servicemembers expressed a 
number of reasons why they chose not to wear the required hearing 
protection. Some servicemembers said the protective equipment was 
uncomfortable. At the sites we visited we spoke with a number of 
servicemembers working on a flight line in close proximity to fighter 
jets who are required to wear double hearing protection. While they 
were generally aware that they were required to wear double 
protection, each was wearing single protection and many cited comfort 
as a reason for their non-compliance. (See figure 5 for an example of 
the proximity of flight line personnel to jet airplanes.) At other 
locations we visited, servicemembers cited the impact of hearing 
protection on communication. They said that the protection can 
interfere with the need to communicate with their colleagues and to 
hear orders from superiors. Still others said they perceived that 
wearing hearing protection in combat can put them in harm's way 
because they cannot hear an enemy approach or determine where enemy 
gunfire is coming from. Finally, many servicemembers expressed the 
view that hearing loss is part of the military experience and many 
accepted this as a fact of a military career. For those that used 
hearing protection equipment, we heard of a number of instances where 
hearing protection equipment was not worn properly. Across many of the 
military sites we visited, servicemembers told us of hearing 
protection either falling out of their ears or getting dirty to the 
point of being unsanitary to wear. 

Figure 5: Example of the Proximity of Flight Line Personnel to 
Military Aircraft: 

[Refer to PDF for image: photograph] 

Source: GAO. 

[End of figure] 

Educating Servicemembers on Hearing Conservation Is Not Necessarily 
Tracked or Well Timed: 

In accordance with DOD policy for the armed services' hearing 
conservation programs, participating servicemembers should be educated 
and trained annually with regard to hearing conservation requirements. 
Per DOD policy, servicemembers should be educated on topics such as 
the effects of noise on hearing and the purpose of hearing protection. 
The policy allows services to design their own specific training. 
Among the sites we visited, servicemembers told us they received 
education on hearing conservation through a variety of training 
methods, including Safety Stand Downs, videos, posters, and supervisor 
initiatives.[Footnote 17] 

Although services have a number of training options for educating 
servicemembers on hearing conservation, officials from some of the 
services reported they were unable to verify whether servicemembers 
have taken any training. For example, Army Hearing Program personnel 
noted that the Army has no method for tracking whether soldiers have 
received such training. Also, Navy hearing conservation personnel told 
us the Navy operates systems for tracking individual training 
activities, but servicemembers are not required to record their 
training in the system. However, Air Force officials require that 
workplace supervisors document a servicemember's annual training on 
hazardous noise exposures and equipment on an Air Force Record of 
Training form. 

We also found that educating servicemembers on hearing conservation is 
not necessarily conducted prior to servicemembers' first exposure to 
hazardous noise or during hearing tests, when they are interfacing 
with audiologists or audiometric technicians with hearing conservation 
expertise. At many of the sites we visited, we were told that 
servicemembers, as new recruits, were given very little education on 
hearing conservation prior to the first time they fire weapons during 
basic training in these locations.[Footnote 18] The education 
generally consisted of instructors telling new recruits to simply use 
hearing protection in their ears, but not explaining its importance or 
the proper technique to insert such equipment. A few servicemembers 
stated they were told not to wear hearing protection during training, 
with the justification that training should be conducted under the 
same conditions as combat, which does not include hearing protection. 
Also, at the sites we visited, a number of servicemembers added that 
educating new recruits on hearing conservation may be difficult during 
basic training because there is little time for any additional 
education. Despite these observations, a number of hearing 
conservation personnel told us that even a single exposure to 
hazardous noise can trigger some level of hearing loss and believe 
that educating new recruits on hearing conservation during basic 
training would help underscore the importance of hearing protection. 
[Footnote 19] 

Lastly, several audiologists and audiometric technicians--hearing 
testing personnel--at sites we visited told us there is no formal 
training in conjunction with the hearing examination process for those 
servicemembers in a hearing conservation program. Similarly, a number 
of servicemembers we spoke with noted that the training they receive 
from hearing testing personnel primarily consists of reminding them to 
wear hearing protection. That stated, several hearing conservation 
personnel at the sites we visited told us they provided more in-depth 
informal training to servicemembers who fail their hearing 
examinations, consisting of an explanation of test results, a 
demonstration on the proper fitting of hearing protection, and a 
reminder to wear hearing protection. 

DOD's Approach to Evaluating Hearing Conservation Has Key Weaknesses, 
While Some Services Have Taken Steps to Review and Improve Their Own 

DOD Lacks Adequate Performance Indicators: 

DOD delegates most program evaluation to the services, but lacks 
adequate performance indicators to proactively assess how well 
services are reducing hearing loss among servicemembers. At the time 
of our review, DOD policy required that services evaluate their 
hearing conservation programs on an annual basis based on two annual 
performance indicators both targeted for servicemembers enrolled in a 
hearing conservation program--(1) the percentage of servicemembers 
that take a required annual hearing test and (2) the rate of 
significant hearing loss.[Footnote 20] Several senior service-level 
hearing program managers expressed concern about the adequacy of the 
indicators. More specifically, they told us that the current 
performance indicators are not sufficiently comprehensive and that the 
rate of significant hearing loss only provides a measure of 
performance after damage has occurred. In general, key officials in 
the services we spoke with expressed a desire for more leading 
indicators that could signal to program managers that targeted 
interventions are needed before hearing loss has occurred. Moreover, 
some Army officials told us that they would like to see indicators 
that are more closely aligned with their readiness--which is a basic 
measure to assess each servicemember's ability to deploy. A senior-
level DOD official told us they convened two working group sessions--
which involved representatives from across the services--since spring 
2010 to discuss amending existing performance indicators. According to 
another senior-level DOD official, additional indicators were put in 
place in December 2010 when DOD released its updated hearing program 
guidance. This guidance includes indicators designed to be more 
proactive in hazard evaluation and intervention prior to measurable 
hearing loss, such as the percentage of noise hazardous workplace 
characterizations completed and an index of unacceptable noise 
exposures. The guidance also encourages services to develop additional 
measures of program effectiveness. 

Limitations in Information System Processes Hinder Program Evaluation 

Program evaluation is also hindered by limitations in the processes 
used to capture, track, and use hearing-related performance data. DOD 
has multiple information systems related to its hearing conservation 
program, including one that tracks servicemember hearing test results 
and another that tracks servicemembers' exposure to occupational noise 
hazards. But officials we spoke with identified limitations in the 
processes designed to support these systems that, collectively, 
compromise the reliability or usefulness of performance data that they 
generate.[Footnote 21] 

We found limitations in the process to identify whether hearing loss 
for an individual may have occurred. Typically, immediately prior to 
administering a hearing test, an audiometric technician will query the 
hearing test system to retrieve a servicemember's prior test results, 
which are used as a baseline with which to establish whether a loss 
has occurred. However, on some occasions, prior hearing test data 
cannot be located in the system and must be entered manually by 
audiometric technicians before they administer the hearing test. For 
example, at one base we visited, if a servicemember did not bring 
their original paper examination to the test, technicians told us they 
would sometimes have to categorize the test as a "non-hearing 
conservation" hearing test or have to re-establish the baseline 
hearing test, making it difficult to assess whether a significant 
hearing loss has occurred because there would not be two comparison 
points. Audiometric technicians must also manually enter into the 
hearing test system whether a servicemember is receiving an initial or 
follow-up hearing test. However, Navy researchers conducting system 
reliability tests told us they have found anomalies in how initial and 
subsequent hearing tests were categorized, making it difficult to tell 
whether tests were given in the proper sequence. They attributed many 
of these problems to technicians' manual data entry errors and the 
lack of a consistent review process to ensure these entries are 
accurate, which undermine the accuracy of the test data. 

We also found limitations in the process to establish that hearing 
loss for an individual has actually occurred. If a hearing loss is 
detected during an annual examination, it is generally considered 
temporary until the hearing loss is confirmed in at least two 
additional follow-up examinations.[Footnote 22] According to DOD 
officials, servicemembers must appear for the follow-up examinations 
within 90 days of an annual test. However, we found that when 
servicemembers who fail their annual tests do not appear for follow-up 
examinations within the required period, the system will automatically 
count their temporary hearing loss as permanent. To the extent this 
occurs, the rate of permanent hearing loss could be inflated. Without 
a reliable rate for hearing loss, services are unable to properly 
assess the effectiveness of their program or properly target 
prevention efforts. 

Finally, in reference to hearing tests, we found limitations in the 
process used to identify the number of servicemembers enrolled in the 
services' respective hearing conservation programs--which is essential 
to calculating the hearing test compliance rate. Because the system 
designed to track hearing tests does not automatically capture the 
number of enrollees, each service must estimate its number from other 
data sources. For example, Air Force hearing program enrollment 
information is maintained in a separate database that does not link to 
the hearing test system. Consequently, Air Force officials resort to 
using an often time-consuming manual process to tally the number of 
servicemembers enrolled in the hearing conservation program. 
Similarly, Navy and Marines officials told us that at some locations, 
officials must construct enrollment information from multiple sources, 
including paper files. Compiling enrollment numbers from multiple 
sources can lead to errors in calculating the compliance rate. For 
example, we found that the Army reported a compliance rate that 
exceeded 100 percent in 2007. 

In reference to the system that tracks hazard exposure information-- 
including the time, place, and amount of servicemembers' exposure to 
hazardous noise--we identified some limitations with the current 
usefulness of the system. This system is designed to track 
servicemembers' occupational exposure to noise and other hazards over 
the course of a military career. However, based on the information we 
received, the system is not yet fully implemented at some 
installations. Moreover, Army industrial hygiene officials at one 
installation told us that they had been trained on the system, but did 
not have the staff resources to upload exposure information into the 
system from individual files. In discussing this issue, Army officials 
told us that 300 new industrial hygiene personnel they expect to hire 
over the next 3 years will aid systems implementation. A senior-level 
Air Force official told us that the Air Force has fully implemented 
the hazard tracking system across all installations. However, Air 
Force industrial hygiene officials expressed concern to us about the 
system's capacity to generate reports in a format that provides useful 
performance information. More specifically, they noted that to get 
critical information about the hazards that exist in each Air Force 
work site, the new system generates a 14-page report. To overcome the 
system's limitations, the Air Force developed a reporting process that 
could produce the same information in 2 pages. A senior-level Air 
Force official told us it is necessary for them to upload hazard 
information twice daily from the new system into an existing Air Force 
form to get the performance information needed to effectively mitigate 
noise hazards on base and meet DOD requirements, respectively. 
Moreover, the hazard exposure tracking system is not currently 
integrated with the hearing test system. DOD initially designed these 
systems with the intent to integrate data from both systems to 
identify the impact of each servicemember's individual exposure to 
noise and other occupational hazards. Although the DOD hearing test 
system has been active since 1999 and the hazard exposure system was 
initiated in 2006, to date, these systems have not been linked. As a 
result, hearing conservation managers told us it is difficult to 
systematically analyze the causes of hearing loss and effectiveness of 
mitigation measures. According to DOD officials, DOD has not 
determined when they plan to integrate the two systems. 

Program Stakeholders Do Not Appear to Routinely Coordinate to Evaluate 
Program Performance: 

Evaluating an installation's implementation of the hearing 
conservation program requires information that often resides across 
various departments on base. This information includes noise hazard 
data; steps actually taken to mitigate hazards; and hearing tests 
results. As indicated by DOD guidance and supported in principle by 
many of the stakeholders we spoke with, it is necessary for various 
stakeholders, including workplace supervisors, industrial hygienists, 
audiologists, and safety officials, to communicate and share 
information about potential noise hazards and hearing loss trends in 
order to effectively manage and evaluate the hearing conservation 
program. However, based on interviews with senior-level officials and 
our site visits, coordination does not appear to routinely occur at 
some bases. For example, at a Navy and Marine base we visited, 
industrial hygienists were responsible for identifying hazardous noise 
at work sites and making recommendations on how to mitigate these 
hazards, but they had no authority to oversee the implementation of 
their recommendations. Across all the services, officials, who reside 
in a separate department from industrial hygienists, are responsible 
for monitoring hearing loss and following up and enforcing industrial 
hygiene recommendations, but we were told on some bases these two 
departments rarely coordinate. At one base we visited, industrial 
hygiene and audiology officials had never met one another prior to our 
visit. However, we did document one instance of effective coordination 
at one Army installation, whereby an audiologist responsible for 
hearing testing identified an increase in hearing loss among 
servicemembers at a particular work site. In order to prevent further 
hearing loss, the audiologist shared this information with the 
industrial hygiene officials on base and they were able to conduct an 
assessment of potential noise hazards and make recommendations to 
mitigate these hazards. 

Services Have Made Efforts to Review and Improve Their Own Hearing 

Each service has taken some steps to review their own hearing 
conservation programs and identify opportunities for improvement. 
These include scheduled reviews of hearing loss data and hearing test 
audits, among other efforts. 

Air Force Occupational and Environmental Health Working Group: 

The Air Force developed a mechanism to aid coordination across 
multiple departments by requiring each base to establish an 
Occupational and Environmental Health Working Group to review data on 
a wide range of health hazards and indicators. At one site we visited, 
the working group had members from multiple departments, including 
Flight Medicine, Safety, Bioenvironmental Engineering, Aerospace 
Physiology, Public Health, and Audiology. Members of the working group 
told us they review hearing loss data each month for each unit on base 
to determine if there are incidences of significant hearing loss. If 
significant loss is identified, the working group will conduct a site 
visit to determine its cause and make recommendations for noise 

Audit of Marine Corps Hearing Tests: 

After the Headquarters Marine Corps Safety Division designated hearing 
loss as a high risk issue for the Marines in fiscal year 2008, the 
Marines requested that the Naval Audit Service conduct an audit of its 
program. The audit focused on audiometric testing and reviewed a 
representative sample of Marines discharged in 2007 to determine how 
many had received hearing tests both at the beginning and end of their 
military service.[Footnote 23] Additionally, the review included an 
assessment of the reliability and consistency of hearing test data and 
a survey of senior leadership on who is responsible for the hearing 
conservation program, how often the program has been evaluated, and 
the effectiveness of these evaluations, action plans, performance 
measures, and standard operating procedures. The audit found that the 
Marine Corps had not effectively protected the hearing of Marine Corps 
personnel and noted that 6,300 Marines from 2001 to 2008 had hearing 
loss or hearing-related injuries. NAS also found that 84 percent of 
the medical records of Marines who left the service in fiscal year 
2007 did not have an entrance or exit audiogram within 60 days of 
their entry or exit from the service. The report makes several 
recommendations to improve the effectiveness of the Marine Corps 
hearing conservation program, including performing a one-time review 
to identify all current Marines who are due for an audiogram and 
establishing controls to ensure that Marines receive timely access to 
care for required audiograms. 

Navy Survey of Hearing Protection Equipment aboard Aircraft Carriers: 

In 2005, the Naval Air Systems Command published a survey of sailors 
aboard six aircraft carriers assessing the extent to which hearing 
protection equipment was being appropriately fitted, used, and 
maintained.[Footnote 24] The study included interviews with flight 
deck personnel on their duties, noise exposure, and their perceptions 
about the adequacy and comfort of their equipment. The reviewers 
reported that almost 50 percent of the sailors surveyed reported never 
wearing earplugs and only 7 percent had inserted the earplugs deeply 
enough to achieve the recommended protection. Moreover, they found 
that, for flight deck personnel studied, 79 percent received noise 
reduction of only 0 to 6 decibels from their equipment--this despite 
working in conditions that required double hearing protection. 
Although helmets were found to be properly fitted for 90 percent of 
those surveyed, some were found to be in poor condition, or to have 
been shared among sailors or worn over hats or scarves. The report 
recommended the following actions: (1) improve the effectiveness of 
hearing protection equipment, including helmets, earplugs, and muffs; 
(2) instruct servicemembers on how to select the proper size and 
correctly wear and maintain hearing protective equipment; (3) make 
hearing protection part of the uniform; and (4) set penalties for 
noncompliance with the appropriate use of hearing protection.[Footnote 

Army Program Review: 

Concerned about the high rate of hearing-related injuries incurred 
during the early stages of Operation Iraqi Freedom, the Army released 
in 2005 a broad-based review of its hearing conservation program with 
regard to training, base, and combat environments.[Footnote 26] The 
reviewers concluded that the Army's hearing conservation program was 
more suitable for industrial rather than military conditions. For 
example, military audiologists were serving in Iraq but their role was 
largely limited to evaluating--not preventing--hearing loss. In 
addition, the review found that the Army's readiness requirements were 
not specific enough to reflect the critical importance of hearing to 
soldiers in combat. The reviewers recommended a number of policy 
changes to make hearing protection policies more effective for active 
duty soldiers, such as requiring that, in order to meet combat 
readiness standards, soldiers must be up to date on their periodic 
hearing tests and be fitted with combat arms earplugs. Subsequently, 
the Army instituted a policy that soldiers who did not meet the 
hearing readiness standard could not be deployed. Army officials we 
spoke with told us that implementing this enhanced readiness standard 
has improved compliance with hearing tests, and have given individual 
soldiers and unit commanders clear accountability for taking steps to 
protect soldier hearing. The Army reported that audiograms increased 
from 168,000 in 2003 to almost 440,000 in 2006; officials attributed 
this increase to the new hearing readiness standard. Several Navy and 
Marine officials with whom we discussed the Army's hearing readiness 
standard expressed interest in considering a similar approach for 
their respective services. 

The same report also recommended that military audiologists be 
assigned broader responsibility for hearing conservation, given their 
combination of medical skills, military training, and knowledge of 
protective and communication equipment designed for combat. In 
response, the Army reports that it plans to increase the number of 
Army military audiologists from 25 to 45. In addition, to determine 
whether the Army's staffing policy would effectively support military 
audiologists' expanded role in hearing conservation, the Army 
conducted a pilot study in 2008 at Fort Carson, Colorado. The Army 
found that an increase from one to two military audiologists at the 
base allowed them to spend time performing preventative services, such 
as training medics and noise-exposed soldiers on proper earplug use, 
giving briefings on hearing conservation, and inspecting noise-
hazardous areas, in addition to their clinical work.[Footnote 27] At 
Fort Carson we observed a military audiologist and medic meeting with 
soldiers on the firing range, assessing earplug fit and answering 
questions, as well as providing individually-fitted combat arms 
earplugs and distributing boxes of foam earplugs in different sizes. 

Plans Are Almost Complete for Both the Hearing Center of Excellence 
and a System to Facilitate DOD and VA Data Sharing: 

A Plan for the Center Has Been Submitted for Final Department Approval: 

DOD has developed, but not yet finalized, its planning for the DOD 
Hearing Center of Excellence that Congress mandated in October 2008 to 
be established. While DOD maintains final authority on decisions for 
the center, it is coordinating the planning effort with the VA and has 
assigned the Air Force responsibility to draft plans for the center. 
The Air Force, in turn, designated an interim director for the center 
in November 2009. Subsequently, the center's interim director 
completed basic logistical planning, such as identifying space and 
budgeting for the center, along with developing proposals to hire 
staff and purchase equipment. He also led the internal workgroup that 
included representatives from all the armed services and VA that 
jointly developed early drafts of the concept of operation for the 
center to delineate its mission, goals and structure. As of September 
2010, each of the armed services had reviewed the current draft. The 
draft was awaiting approval by the DOD Assistant Secretary of Defense 
of Health Affairs before it could be sent to the VA for approval. 
Neither Congress nor DOD set a date for when planning should be 
formally approved to implement the center, but a key DOD official 
estimated that the concept of operations may get final DOD approval in 
the near future. 

As described by the center's interim director and Air Force Surgeon 
General, the current plan envisions a "hub-and-spoke concept"----the 
center's headquarters as the hub and selected DOD and VA regional 
medical centers and research sites as spokes--to integrate, 
facilitate, and coordinate clinical care and research for 
servicemembers and veterans with the latest treatment and research on 
hearing loss, tinnitus, and auditory system injury.[Footnote 28] The 
Lackland Air Force Base in San Antonio, Texas, will serve as 
headquarters, while the regional sites have yet to be named. The 
director told us that the plan also describes the center as 
facilitating the sharing of information between DOD and VA on clinical 
advances related to the management and rehabilitation of hearing loss 
and injury. This arrangement is intended to optimize clinical care and 
research and avoid unnecessary duplication. DOD also has planned for 
possible consolidation of common support functions, such as 
administrative support and contract support, for all the DOD centers 
of excellence to help ensure operational economy and efficiency. 
[Footnote 29] 

Furthermore, the interim director told us that the focus of the center 
will be to: 

* research and support field testing of the best available protection 
and communication devices currently available, as well as developing 
improved hearing protection, along with better education and training 
on its use; 

* create best practice guidelines for improving hearing outcomes after 
injury and explore new lines of therapy to protect or restore hearing 
loss or injury; 

* determine how many hazardous noise exposures are too many for a 
servicemember and the level of hearing needed for selected jobs to 
facilitate appropriate job assignments; 

* develop and implement better restorative and rehabilitative devices; 

* promote standards for implementing hearing awareness and treatment 
into medical air evacuations for injured troops; and: 

* collaborate with academic centers and industry in all these pursuits 
to mitigate or restore hearing loss. 

Data Sharing between DOD and VA Is Expected to Increase with 
Implementation of a New Electronic System: 

While attempts have been made by DOD and VA to share data, officials 
from both departments told us that a new data sharing system is needed 
so that sufficient information is available to address hearing 
injuries and loss, such as assessing the effectiveness of the DOD and 
armed service hearing conservation programs, providing and assessing 
treatment, and making disability compensation decisions.[Footnote 30] 
A recent data sharing experience between the two departments 
demonstrates some of the current weaknesses that may be resolved by 
the pending implementation of a new data system. In January 2010, VA 
responded to the hearing center's interim director's request for data 
to help evaluate the scope and rate of hearing loss specific to each 
service. VA was able to provide much of the information requested, 
such as the number of new VA approved claims for hearing loss and 
tinnitus grouped by each military branch of service and the disability 
rating,[Footnote 31] for each year from 2004 through 2009. However, 
VA's system, developed to process claims and make disability payments, 
was not able to provide the other data requested in a format to meet 
DOD's needs for information on all claimants with hearing loss, such 
as date of separation from the military, period of military service, 
and military job. Without this additional information, the center's 
interim director reported to us that he could not sufficiently 
evaluate the military's hearing conservation programs, in part, 
because he could not determine the rate or trends of unique claims 
that could be attributable to the current conflict, specific at-risk 
locations or duties, or prevention efforts. 

Although not yet finished, the plan for a comprehensive "registry"--
for tracking and exchanging data between DOD and the VA on hearing 
loss, injury, treatment, and outcomes--is close to completion. While 
the concept of operations for the registry was initially expected to 
be developed for final review by the Assistant Secretary of Defense by 
July 2010, it was still under preliminary review by the armed services 
and the VA as of late 2010. According to the center's interim director 
and a working group member, the development of the registry's plan 
will be facilitated by borrowing from the design of the Vision Center 
of Excellence's registry, such as using some of the same data fields 
and data sources for both registries. The interim director also told 
us that the hearing center's registry would use data from the existing 
DOD and VA systems. Pending DOD approval of the registry plan, the 
interim director anticipates launching a pilot registry in the summer 
of 2012. 

A key DOD official, armed services officials, and VA officials told us 
they expect the registry to provide a wealth of information to assess 
techniques for hearing protection and to develop best practices for 
treatment of those with hearing loss and injury. They expect the 
registry data to contain information on hearing loss and injury 
incurred during active duty, by virtue of tracking servicemembers' 
injuries, interventions, and outcomes. According to the center's 
interim director, this information will enable the armed services to 
better assess their hearing conservation programs, hearing protective 
efforts, therapies and procedures for auditory injury, and 
rehabilitation. The center's efforts could, he noted, reduce hearing 
impairments and with it, the cost of VA compensation for hearing loss. 

The Center's Interim Director Has Been Laying the Groundwork to 
Facilitate the Implementation of the Center and Data System: 

In preparation for implementation, the center's interim director has 
taken a number of steps to build alliances with academic institutions 
to address prevention, clinical care, rehabilitation, and research 
gaps. For example, to establish visibility for the center and build 
relationships with academic institutions, the director has contacted 
the Deafness Research Foundation, which has an alliance of 10 
laboratories that conduct stem cell, metabolic, and other types of 
restoration research for hearing injuries and loss. According to the 
center's interim director, this alliance is needed because DOD and VA 
lack resources and expertise in this area. In February 2010, the 
interim director facilitated a symposium of academics and officials 
from DOD and VA on addressing war fighter injuries. The group 
identified 23 relevant research projects and several areas of focus 
for the center's research. 

Additional steps taken to prioritize and facilitate research on 
prevention and treatment include (1) spearheading the formulation of a 
white paper to identify gaps and propose solutions to coordinate and 
link research efforts across DOD and VA hearing research labs and 
clinical sites and (2) initiating discussions to create within DOD a 
centralized and independent Institutional Review Board to be linked 
with VA's centralized Institutional Review Board. The center's interim 
director envisions that such a board would not only meet the standard 
research requirement for an independent body to protect patients and 
patient data, but would also shorten the time it takes for any of 
DOD's Centers of Excellence to get board approval for research and 
access to data. 

With regard to the data sharing network that includes the registry, 
the center's interim director has taken a number of steps to develop 
its capacity. To move forward with data sharing, he has requested a 
military-wide health system certification of auditory software that is 
needed to allow DOD and VA to collect and share hearing test results. 
The hearing center registry has also been developed so that it can 
linked with other registries and centers, to help integrate 
servicemember data on hearing with other sensory deficits, as well as 
traumatic brain injury. He has also assisted with the development of a 
module to include auditory data collection in DOD's front-line medical 
treatment information registry.[Footnote 32] 


Good hearing is critical to a servicemember's performance and well- 
being, whether in combat or in carrying out peaceful operations. The 
U.S. military system has, in recent years, undertaken measures to 
preserve the hearing of military personnel and alter the assumption 
that military duty must inevitably lead to a loss in hearing capacity. 
Nevertheless, hearing loss and tinnitus remain conditions that most 
often require disability compensation for veterans. Yet both are 
largely preventable. 

The inconsistencies that we found in the various military strategies 
for hearing protection and the lack of good monitoring and oversight 
suggests that these programs are not realizing their full potential. 
The fact that new servicemembers do not necessarily receive 
instruction on using protective equipment before they are exposed to 
hazardous noise in basic training, for example, undermines the first 
stage of any defense, which is prevention. Moreover, servicemembers 
enrolled in a hearing protection program that do not necessarily 
receive more education and training when they appear for their 
periodic exams represent another lost opportunity for hearing loss 
prevention. Aside from the lack of more thorough and carefully timed 
training programs, the services and DOD have no uniform system for 
tracking who has received training on hearing loss prevention. The 
services and DOD must ensure that service personnel are cognizant of 
the immediate and long term risks to hearing posed by exposure to 
hazardous noise. 

In terms of strategy, DOD itself is not in a position to assess the 
adequacy of the programs and practices it now requires of the services 
for hearing preservation without a full set of performance indicators. 
Additionally, without more reliable data and reporting capability, and 
an integrated system of records that relate hearing injuries to work 
sites, DOD will further lack the ability to approach the problem of 
hearing loss more strategically--by capitalizing on areas of success 
and targeting areas of weakness. 

While each of the services has made some effort to review and improve 
its hearing loss prevention practices, weaknesses remain in DOD 
efforts to identify and mitigate hazardous noise. Some of these 
individual initiatives, if expanded across each of the services, 
likely hold promise for addressing these issues. Without efforts to 
expand these initiatives, new insights and improvements could be lost--
to the detriment of the services and servicemembers. 

Recommendations for Executive Action: 

To position DOD and the services to better protect servicemembers from 
hearing loss, we recommend that the Under Secretary for Personnel and 
Readiness work with the Assistant Secretary for Health Affairs and 
take the following four actions to ensure that: 

* DOD and the services improve upon the type, timing, and tracking of 
training and education provided to servicemembers on hearing 
protection, by providing information that is more comprehensive and 
training that is more frequent and possibly earlier in servicemembers' 

* DOD work with the services to develop an appropriate set of 
performance indicators that assess how well services are reducing 
hearing loss among servicemembers. 

* DOD and the services address limitations in the processes used to 
capture, track, and use performance data. This effort should address 
issues with data reliability, data entry, reporting capability, and 
integration across relevant databases. 

* DOD work with the services to examine the appropriateness and 
feasibility of expanding those service-level initiatives that hold 
promise of improving---on a DOD-wide basis---the military hearing 
conservation programs. Particular attention should be focused on those 
efforts that already appear to have either increased compliance with 
program requirements or have demonstrated the potential to reduce 
hearing loss among servicemembers, such as establishing hearing loss 
as a readiness issue, improving the comfort and design of hearing 
protection, and including noise experts more consistently in the 
procurement process. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to DOD and VA for review and 
comment. DOD provided written comments and agreed with our 
recommendations. DOD's comments have been reproduced in appendix II. 
VA did not provide formal written comments, but both DOD and VA 
submitted technical changes to the draft of the report, which we 
incorporated into the report as appropriate. 

In its comments, DOD stated the agency's ongoing and planned actions 
in response to our recommendations. Specifically, to improve upon the 
type, timing and tracking of hearing conservation training provided to 
servicemembers, DOD plans to monitor the progress of the services in 
their efforts to implement improvements, encourage the sharing of 
lessons learned, and standardize improvements across services as 
appropriate. DOD agreed with our recommendation to more proactively 
assess how well services are reducing servicemembers' hearing loss. As 
noted in our report, in December 2010, DOD issued updated guidance 
that included new performance indicators designed to be more proactive 
in hazard evaluation and intervention prior to measurable hearing 
loss. The services also plan to review these indicators and develop 
additional indicators as needed. DOD also stated that it plans to 
address limitations in the processes used to capture, track, and use 
performance data. In addition, DOD agreed to work with the services to 
examine the appropriateness and feasibility of expanding DOD-wide 
those service-level initiatives that hold promise of improving the 
military hearing conservation programs. To this end, DOD stated that 
it will continue to use its annual Safety and Occupational Health In-
Progress Review and the DOD Hearing Conservation Work Group as 
mechanisms of sharing service-level improvement initiatives. Our 
review of the department's new guidance and its planned actions 
indicate that DOD is taking steps in the right direction. If the 
department follows through with its efforts, we believe that it will 
be responsive to our recommendations. 

We are sending copies of this report to the Secretaries of Defense and 
Veterans Affairs, interested congressional committees, and other 
interested parties. The report also is available at no charge on the 
GAO Web site at [hyperlink,]. 

Please contact me on (202) 512-7215 if you or your staff have any 
questions about this report. Contact point for our offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this report. Key contributors to this report are listed in 
appendix III. 

Signed by: 

Daniel Bertoni: 
Director, Education, Workforce, and Income Security Issues: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

To address the objectives of this study, we used a variety of methods 

* reviewed professional journal articles and studies on audiology, 
military audiology, and hearing conservation; 

* researched relevant federal laws, regulations, standards, and 
Department of Defense (DOD) and armed services' guidance; 

* interviewed 12 military and civilian audiologists, 5 audiology 
technicians, 30 representatives of professions who assess, measure, 
and mitigate occupational health hazards such as industrial hygienists 
and safety officials, and 123 servicemembers across each of the armed 
services; and: 

* interviewed senior-level officials from DOD, Veterans' Affairs (VA), 
and the armed services, including the Army, the Navy, the Air Force 
and the Marines. We also conducted informational interviews with 
officials at the National Institute of Occupational Safety and Health 
(NIOSH), the Occupational Safety and Health Administration (OSHA), and 
the Institute of Medicine. 

To review how well the services identify and mitigate hazardous noise 
and evaluate their hearing conservation programs, we visited nine 
military installations across the country--with at least two locations 
for each of the armed services, to review hearing conservation 
activities and interviewed officials both responsible for and 
participating in each base's hearing conservation program. (See table 
2.) We selected sites to visit based on the size of the installation, 
the presence of hazardous noise, and geographic location. During our 
site visits, we met with senior officials from the installation and 
public health commands and interviewed audiologists, audiometric 
technicians, industrial hygienists, other occupational safety 
personnel as well as servicemembers with experience in combat or other 
missions with hazardous noise. We visited various installation work 
sites, including maintenance shops, a firing range, and an aircraft 
carrier to observe signs and labels designating hazardous noise areas 
or equipment; the availability of hearing protection equipment in or 
around such areas; and the use of personal hearing protection. We also 
observed audiologists and technicians conduct hearing conservation 
activities, including performing hearing tests, interviewing and 
educating servicemembers about hearing protection, and assessing 
appropriate fit and use of hearing protection equipment at noise 
hazardous sites. 

Table 2: Military Bases Visited during GAO Review of Hearing 
Conservation Programs: 

Service: Army; 
Base: Fort Meade (MD); 
Noise-hazardous areas observed: Vehicle security. 

Service: Army; 
Base: Fort Carson (CO); 
Noise-hazardous areas observed: Firing range. 

Service: Navy; 
Base: Naval Station Norfolk (VA); 
Noise-hazardous areas observed: Aircraft carrier. 

Service: Navy; 
Base: Naval Station San Diego (CA); 
Noise-hazardous areas observed: Aircraft carrier. 

Service: Air Force; 
Base: Andrews Air Force Base (MD); 
Noise-hazardous areas observed: Maintenance shop. 

Service: Air Force; 
Base: Eglin Air Force Base (FL); 
Noise-hazardous areas observed: Maintenance shop. 

Service: Marine Corps; 
Base: Marine Corps Base Quantico (VA); 
Noise-hazardous areas observed: Air facility. 

Service: Marine Corps; 
Base: Marine Corps Base Camp Lejeune (NC); 
Noise-hazardous areas observed: Tank maintenance shop. 

Service: Marine Corps; 
Base: Marine Corps Base Cherry Point (NC); 
Noise-hazardous areas observed: Military aircraft, ground operations, 
and aircraft maintenance hangar. 

Source: GAO. 

[End of table] 

To further review DOD and the services' program evaluation efforts, we 
discussed performance goals, measures, and information systems at the 
leadership and the installation levels. We interviewed officials from 
NIOSH and OSHA--organizations responsible for creating hearing 
conservation program review standards for civilian workers, as well as 
DOD and armed services officials responsible for oversight of military 
hearing conservation programs. More specifically, we interviewed DOD 
officials and reviewed documentation related to the armed services' 
program evaluation activities, such as setting targets and reviewing 
performance trends. To determine the availability and usefulness of 
information to support program evaluation, we interviewed officials 
responsible for managing DOD's hearing conservation data system as 
well as officials who are familiar with and use the system, including 
installation hearing conservation program managers and technicians. We 
reviewed data dictionaries and other technical documentation for the 
Defense Occupational and Environmental Health System (DOEHRS), DOD's 
database for tracking servicemembers' hearing test results and their 
occupational exposure to noise and other hazards. After an internal 
review of standard data reports provided by the services, we 
determined that it would not be feasible to validate data consistent 
with GAO's reliability standards within our planned time frames. 

To determine the status of the DOD Hearing Center of Excellence and 
its registry and efforts to share information to improve hearing 
protection, we interviewed officials from DOD, including the center's 
interim director and the representatives of the armed services and VA 
involved in these efforts. We also reviewed planning documents for the 
center and registry and data shared between DOD and VA. 

[End of section] 

Appendix II: Comments from the Department of Defense: 

Office Of The Under Secretary Of Defense: 
Acquisition, Technology And Logistics: 
3010 Defense Pentagon: 
Washington, DC 20301-3010: 

January 19, 2011: 

Mr. Daniel Bertoni: 
Director, Education, Workforce, and Income Security Issues: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Dear Mr. Bertoni: 

This is the Department of Defense (DoD) response to the GAO Draft 
Report, GAO-11-114, "Hearing Loss Prevention: Improvements to DOD 
Hearing Conservation Program Could Lead to Better Outcomes," dated 
December 7, 2010 (GAO Code 130967). 

We provide in the enclosure the DoD responses to the GAO 
recommendations. We concur with all recommendations. 


Signed by: 

Dorothy Robyn: 
Deputy Under Secretary of Defense (Installations and Environment): 

Enclosures: As stated: 

[End of letter] 

GAO Draft Report Dated December 7, 2010: 
GAO-11-114 (GAO Code 130967): 

"Hearing Loss Prevention: Improvements To Dod Hearing Conservation 
Program Could Lead To Better Outcomes" 

Department Of Defense Comments To The GAO Recommendations: 

Recommendation 1: DoD and the services improve upon the type, timing, 
and tracking of training and education provided to servicemembers on 
hearing protection, by providing information that is more 
comprehensive and training that is more frequent and possibly earlier 
in servicemembers careers. 

DoD RESPONSE: Concur. The Military Services are in various stages of 
developing and implementing improvements to the type, timing, and 
tracking of training and education of service members. The Office of 
the Secretary of Defense (OSD) will monitor progress of the Military 
Services in implementing improvements, provide for cross-flow of the 
lessons learned across the Military Services' improvements, and 
standardize those improvements across all Military Services as 

Recommendation 2: DoD work with the services to develop an appropriate 
set of performance indicators that assess how well services are 
reducing hearing loss among servicemembers. 

DoD Response: Concur. Improved DoD performance indicators were issued 
in the update to DoD Instruction 6055.12, "Hearing Conservation 
Program (HCP)," dated December 3, 2010. The Military Services will 
review these indicators and develop additional indicators as needed to 
assist them in monitoring program execution and effectiveness. 

Recommendation 3: DoD and the services address limitations in the 
processes used to capture, track, and use performance data. This 
effort should address issues with data reliability, data entry, 
reporting capability, and integration across relevant databases. 

DoD Response: Concur. OSD and the Military Services will address a) 
limitations in the processes used to capture, track, and use 
performance data, and b) issues with data reliability, data entry, 
reporting capability, and integration across relevant databases. 

Recommendation 4: DoD work with the services to examine the 
appropriateness and feasibility of expanding those service-level 
initiatives that hold promise of improving ---on a DoD-wide basis--- 
the military hearing conservation programs. Particular attention 
should be focused on those efforts that already appear to have either 
increased compliance with program requirements or have demonstrated 
the potential to reduce hearing loss among servicemembers, 
such as establishing hearing loss as a readiness issue, improving the 
comfort and design of hearing protection, and including noise experts 
more consistently in the procurement process. 

DoD Response: Concur. OSD will continue to use the annual Safety & 
Occupational Health In-Progress Review and the DoD Hearing 
Conservation Work Group as mechanisms for direct cross-flow and 
application of individual Military Service improvement initiatives. 
Examples of initiatives include: standardizing criteria for evaluating 
hearing protection devices for entry into a qualified products list; 
improving the processes for weapon system procurement and use of 
engineering controls; implementing management system approaches that 
achieve high audiometric exam compliance rates; consolidating 
requirements for research and development of improved hearing 
protection; and using the results from audits of Military Service 
programs to improve compliance with safety requirements. 

[End of section] 

Appendix III: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Daniel Bertoni (202) 512-7215 or 


Brett Fallavollita (Assistant Director) and Michelle Bracy (Analyst-in-
Charge) managed all aspects of the assignment. Julie DeVault, David 
Forgosh, Suzanne Rubins, and Melissa Baker made significant 
contributions to all aspects of this report. In addition, Walter Vance 
and Beverly Ross provided technical support in the design and 
methodology; James Rebbe provided legal support; Susan Bernstein and 
Mimi Nguyen assisted in the message and report development; and Sara 
Edmondson, Jessica Gray, Jonathan McMurray, and Ronni Schwartz 
assisted with quality assurance. 

[End of section] 


[1] S. Rept. No. 111-35, at 146, accompanying the National Defense 
Authorization Act for Fiscal Year 2010, Pub. L. No. 111-84 (Oct. 28, 

[2] VA, Veterans Benefits Administration Annual Benefits Report Fiscal 
Year 2009 (Washington, D.C.) p. 5. 

[3] VA, Rehabilitation Research and Development, National Center for 
Rehabilitative Auditory Research, Annual Report for Calendar Year 2009 
(Portland, Ore.) p. 88. 

[4] Dr. Lucille B. Beck, Chief Consultant, Rehabilitation Services and 
Director of Audiology, VA, "Update on Audiology," p. 15. 

[5] The IOM study also stated that in 1948, the Air Force was the 
first armed services to issue hearing conservation regulations, with 
the Navy following suit in 1955 and the Army in 1956. See Larry E. 
Humes, Lois M. Joellenbeck, and Jane S. Durch, editors, Committee on 
Noise-Induced Hearing Loss and Tinnitus Associated with Military 
Service from World War II to the Present, Noise and Military Service: 
Implications for Hearing Loss and Tinnitus (Washington, D.C.: The 
National Academies Press, 2005). 

[6] DOD defines this threshold level of noise as (1) continuous or 
intermittent noise that has an 8-hour time-weighted average noise 
level of 85 decibels or above, (2) impulse noise with sound pressure 
levels of 140 decibels or greater, and (3) "uppersonic and ultrasonic 
acoustic radiation" determined to be hazardous (DODI 6055.12, 6.2). 

[7] DODI 6055.1, E3.4.2.1. 

[8] DOD's hearing conservation program instruction also includes 
several other elements that we did not focus our review upon, such as 
access to information, training material, and records and personnel 

[9] Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 104, 116 
Stat. 2822 (2002). 

[10] Humes, Joellenbeck, and Durch, "Noise and Military Service: 
Implications for Hearing Loss and Tinnitus." 

[11] U. S. Department of the Navy, Naval Audit Service, Management and 
Implementation of the Marine Corps Hearing Conservation Program (Jan. 
14, 2011). 

[12] Duncan Hunter National Defense Authorization Act for Fiscal Year 
2009, Pub. L. No. 110-417, Div. A. tit. VII, § 721, 122 Stat. 4506 

[13] A sound level meter is the basic instrument for investigating 
noise levels and can be used to determine an employee's noise dose 
whenever use of a noise dosimeter is unavailable or inappropriate. 
Sound level meters identify and evaluate individual noise sources for 
abatement purposes, aid in determining the feasibility of engineering 
controls for individual noise sources, and evaluate hearing 
protectors. A dosimeter is worn by individuals in order to determine 
noise doses during a specified time period. 

[14] Navy policy states that it is much less costly to eliminate 
potential noise problems in the design or procurement stage for new 
processes, equipment, and facilities than it is to make retrofits or 
modifications after the fact. 

[15] Pursuant to OSHA regulations at 29 C.F.R. § 1910.95(b)(2), the 
minimum level at which noise protection measures must be taken is 90 

[16] Hearing protection devices are expected to reduce noise to safer 
levels. Depending on the intensity of the noise, services will require 
two forms, or double, hearing protection being worn at the same time, 
to further reduce noise. 

[17] Safety Stand Downs focus on correcting safety deficiencies and 
conducting safety training that will result in changes in behavior to 
prevent accidents and injuries and protect property. 

[18] Although not part of DOD policy, hearing conservation personnel 
told us servicemembers are enrolled into a hearing conservation 
program based on their occupation or where they work, which occurs 
after basic training. 

[19] The Army has recently initiated a pilot program to incorporate 
hearing protection into basic training. 

[20] STS or significant hearing loss occurs when there is a change in 
hearing threshold relative to an initial hearing test result of an 
average of 10 decibels. 

[21] The Defense Occupational and Environmental Health Readiness System 
- Hearing Conservation (DOEHRS-HC) provides the ability to conduct and 
track automated baseline, annual, pre-and post-deployment hearing test 
results. The Defense Occupational and Environmental Health Readiness 
System-Industrial Hygiene (DOEHRS-IH) is used to collect, maintain, 
and analyze hazard and exposure data. 

[22] In the Air Force, only one follow-up examination is required to 
confirm that permanent hearing loss has occurred. 

[23] U. S. Department of the Navy. Naval Audit Service, Management and 
Implementation of the Marine Corps Hearing Conservation Program (Jan. 
14, 2011). 

[24] Bjorn, V.S.; Albery, C.B.; Shilling, R.; and McKinley, R.L. 
(2005), "U.S. Navy Flight Deck Hearing Protection Use Trends: Survey 

[25] Participants in this study were self-selected or were asked to 
participate by their commanders. Information about whether 
participants regularly wear hearing protection was self-reported and 
there was no objective measure or corroborating information used to 
assess this self-reported information. The information in this study 
is not generalizable and only applies to the six aircraft carriers 
that were tested. However, researchers did provide some information 
comparing the studied population to the overall Navy population, but 
did not directly assess similarities and differences on measured 

[26] Gates, Kathy (Col.) and Fallon, Eric (Ltc.), "Army Hearing 
Conservation Program Analysis" (June 2005). 

[27] Cleveland, Leanne (Cpt.), "Fort Carson: An Army Hearing Program 
Success Story," Army Department Medical Journal, April-June 2009. This 
study describes the effect of the addition of a second audiologist at 
the Army base in Fort Carson, Colo. While the study proves that the 
addition of the second audiologist would increase the number of 
servicemembers receiving testing and training, it does not provide 
sufficient evidence to support that an additional audiologist led to 
reduced hearing loss. For example, the study interprets shifts in the 
hearing loss and readiness rates as being directly attributable to the 
availability of a second audiologist, but the study does not consider 
other factors that could also have had effects, such as overseas 
deployments, changes in equipment, and changes in training. 

[28] Department of Defense Medical Centers of Excellence: Hearing 
before the House Comm. on Armed Services, 111TH Congress (2010) 
(statement of Lt. Gen. Charles B. Green, Surgeon General, U.S. Air 

[29] Senate Report No. 111-20, accompanying S. 1054 (providing 
supplemental appropriations for fiscal year 2009) directed DOD to 
develop a strategic plan for locating, staffing, and resourcing of 
medical centers of excellence to ensure they can provide "the highest 
quality of care, treatment and utilization of research funds for 
servicemembers who are suffering wounds from war." As of late 2010, 
DOD had drafted but not finalized its strategic plan to respond to the 
Senate report. The medical centers of excellence currently include: 
the Hearing Center of Excellence (HCE), the Defense Centers of 
Excellence for Psychological Health and Traumatic Brain Injury (DCoE), 
the Vision Center of Excellence (VCE), and the Extremity Injury and 
Amputation Center of Excellence (EACE). 

[30] DOD and VA are required to develop and implement electronic 
health record systems and to accelerate the exchange of health care 
information between the departments. National Defense Authorization 
Act for Fiscal Year 2008, Pub. L. No. 110-181, § 1635, 122 Stat. 460 
(2008). According to a recent GAO report, the departments are now 
exchanging pharmacy and drug allergy data on patients. For more 
information on their progress, see GAO, Electronic Health Records: 
DOD's and VA's Sharing of Information Could Benefit from Improved 
Management, [hyperlink,] 
(Washington, D.C.: Jan. 28, 2009). 

[31] After VA determines that a claimed disability is related to a 
veteran's military service, VA assigns a percentage rating to the 
disability that corresponds to the disability's severity. The ratings 
range from 0 percent to 100 percent and are assigned in increments of 
10 percent. 

[32] DOD uses its Joint Theater Trauma System and Joint Theater Trauma 
Registry to collect data and improve the outcomes of soldiers injured 
on the battlefield. 

[End of section] 

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