Military Hearing Loss Medical Waiver Form
Complete this form to request or document a military hearing-loss waiver. Provide only the information needed for the waiver process.
Applicant Information
Applicant Full Name
*
First Name
Middle Name
Last Name
Military Branch or Service Affiliation
*
Please Select
Army
Navy
Air Force
Marine Corps
Space Force
Coast Guard
Other
Rank or Grade
*
Please Select
Enlisted
Warrant Officer
Commissioned Officer
Civilian Staff
Other
Unit or Command
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Hearing Loss Details
Type of hearing issue
*
Unilateral
Bilateral
Temporary
Permanent
Unknown
Other
Approximate onset date or date first noticed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Formally evaluated by a clinician
*
Yes
No
Unknown
Describe how this hearing loss affects daily tasks or military duties
Waiver Acknowledgment and Signature
Applicant Signature
*
Submit
Submit
Should be Empty: