Workplace Noise Level Evaluation Form
Workplace Noise Level Evaluation Form
Please complete the following sections of this form.
Basic Information
|
Item |
Description |
|
Assessment Date: |
[Month Day, Year] |
|
Department/Location: |
|
|
Number of Employees: |
|
|
Type of Work: |
|
|
Shift Duration: |
Noise Sources
|
Source of Noise |
Description |
|
Machinery/Equipment: |
[Soldering Stations, Conveyor Belts] |
|
Other Sources: |
Noise Level Measurement
|
Measurement |
Value (dB) |
Time/Duration |
|
Average Noise Level: |
[75] |
[Throughout the shift] |
|
Peak Noise Level: |
Hearing Discomfort Reports:
-
Yes
-
No
Headaches/Concentration Issues:
-
Yes
-
No
Comments on Noise Levels:
|
[Employees find the noise level manageable but occasionally distracting.] |
Personal Protective Equipment (PPE)
PPE Provided:
-
Yes
-
No
Types of PPE:
PPE Usage Frequency:
Noise Control Measures
Current Measures:
Noise Control Suggestions:
PPE Improvements:
Other Recommendations:
Other Recommendations:
Evaluator's Signature:
[Your Name]
[Job Title]
[Month Day, Year]
