1. User Information

Name:

[Your Name]

Job Title/Position:

[Your Job Title]

Department/Area:

[Your Department Name/Work Area]

2. Exposure to Noise

Describe your typical exposure to noise in your work area.

Regular exposure to machinery noise.

How many hours per day are you exposed to high noise levels?

Approximately 6 hours daily.

3. Type of Hearing Protection Used

Earplugs/Earmuffs/Both

• Earplugs

• Earmuffs

• Both

Why did you choose this type of hearing protection?

Earplugs are more comfortable and less intrusive for me while working around machines.

4. Fit and Comfort

How well do your hearing protection devices fit?

(Rate 1-5)

4

Have you experienced any discomfort while using your hearing protection? (Yes/No)

If yes, please explain.

No significant discomfort, but minor irritation after prolonged use.

5. Effectiveness of Hearing Protection

Do you feel your hearing protection effectively reduces noise exposure? (Yes/No)

Yes

Have you experienced any hearing difficulties or discomfort while using the hearing protection? (Yes/No)

If yes, please describe.

No

6. Maintenance and Hygiene

How do you maintain and clean your hearing protection devices?

Daily cleaning with a soft cloth; stored in a clean case.

How often do you replace or service your hearing protection?

Replace disposable earplugs daily; earmuffs are inspected and cleaned monthly.

7. Training and Awareness

Have you received training on hearing protection and noise hazards? (Yes/No) 

Yes, attended a workshop last year.

How would you rate your awareness of the importance of hearing protection? 

• Low

• Moderate

• High