###  EMPLOYEE NOISE EXPOSURE QUESTIONNAIRE

+----------------+----+----+------+------------+------------+-------+
| EMPLOYEE NAME  |    | DI |      | DATE STS   | INTERVIEW  | BNL   |
|                |    | VI |      |            | DATE       | LIFE# |
| \_\_           |    | SI |      | STS        |            |       |
| \_\_\_\_\_\_\_ |    | ON |      | \_\_\_     |            |       |
| \_\_\_\_\_\_\_ |    |    |      | \_\_\_\_dB |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| LAST INITIALS  |    |    |      |            |            |       |
+----------------+----+----+------+------------+------------+-------+
| CURRENT        | S  | HC |      | SUPERVISOR |            | PHONE |
| AMBIENT SPL    | LM | P  |      |            |            |       |
| RANGE          |    | RO |      | \_\_\_     |            |       |
|                | BN | GR |      | \_\_\_\_\_ |            |       |
| \_\            | L# | AM |      | \_\_\_\_\_ |            |       |
| _\_\_\_\_\_\_\ |    |    |      | \_\_\_\_\_ |            |       |
| _\_\_\_\_dB(A) |    | PA |      | \_\_\_\_\_ |            |       |
|                |    | RT |      | \_\_\_\_\_ |            |       |
|                |    | IC |      | \_\_\_\_\_ |            |       |
|                |    | IP |      | \_\_\_\_\_ |            |       |
|                |    | AN |      |            |            |       |
|                |    | T? |      | LAST,      |            |       |
|                |    |   |      | FIRST      |            |       |
|                |    | Y  |      | INITIALS   |            |       |
|                |    | ES |      | BADGE \#   |            |       |
|                |    |   |      |            |            |       |
|                |    | NO |      |            |            |       |
+----------------+----+----+------+------------+------------+-------+
| REQUESTOR      |    |    | SHSD |            |            |       |
|                |    |    | INVE |            |            |       |
| \_\_           |    |    | STIG |            |            |       |
| \_\_\_\_\_\_\_ |    |    | ATOR |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    | \_\_ |            |            |       |
| \_\_\_         |    |    | \_\_ |            |            |       |
| \_\_\_\_\_\_\_ |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
| LAST, FIRST    |    |    | \_\_ |            |            |       |
| BADGE \#       |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_   |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    | \_\_ |            |            |       |
|                |    |    |      |            |            |       |
|                |    |    | L    |            |            |       |
|                |    |    | AST, |            |            |       |
|                |    |    | F    |            |            |       |
|                |    |    | IRST |            |            |       |
|                |    |    | INIT |            |            |       |
|                |    |    | IALS |            |            |       |
|                |    |    | B    |            |            |       |
|                |    |    | ADGE |            |            |       |
|                |    |    | \#   |            |            |       |
+----------------+----+----+------+------------+------------+-------+
| Job Title:     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| How Long?      |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Job            |    |    |      |            |            |       |
| Description:   |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Does the       |    |    |      |            |            |       |
| employee work  |    |    |      |            |            |       |
| in areas or    |    |    |      |            |            |       |
| use equipment  |    |    |      |            |            |       |
| that employee  |    |    |      |            |            |       |
| considers loud |    |    |      |            |            |       |
| or that is     |    |    |      |            |            |       |
| labeled as a   |    |    |      |            |            |       |
| hazardous      |    |    |      |            |            |       |
| noise area?   |    |    |      |            |            |       |
| Yes  No If    |    |    |      |            |            |       |
| yes, please    |    |    |      |            |            |       |
| describe.      |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Loca           |    |    |      |            |            |       |
| tion/Equipment |    |    |      |            |            |       |
| Duration       |    |    |      |            |            |       |
| Frequency Ave. |    |    |      |            |            |       |
| SPL            |    |    |      |            |            |       |
| Con            |    |    |      |            |            |       |
| tinuous/Impact |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| \_\_\_\_       |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_           |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| \_\_\_\_       |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_           |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| \_\_\_\_       |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_             |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Comm           |    |    |      |            |            |       |
| ents/Controls: |    |    |      |            |            |       |
| \_\_\_\_\_\_   |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
+----------------+----+----+------+------------+------------+-------+
| Was the        |    |    |      |            |            |       |
| employee       |    |    |      |            |            |       |
| exposed to     |    |    |      |            |            |       |
| loud noises on |    |    |      |            |            |       |
| previous jobs? |    |    |      |            |            |       |
|  Yes  No If  |    |    |      |            |            |       |
| yes, please    |    |    |      |            |            |       |
| describe.      |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Date Type of   |    |    |      |            |            |       |
| Job Equipment  |    |    |      |            |            |       |
| Duration       |    |    |      |            |            |       |
| Frequency Ave. |    |    |      |            |            |       |
| SPL            |    |    |      |            |            |       |
| Cont/Impact    |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_       |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_         |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_       |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_         |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_       |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_         |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_       |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_         |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_       |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_         |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_       |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_         |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_     |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Comments:      |    |    |      |            |            |       |
| \_\_           |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
+----------------+----+----+------+------------+------------+-------+
| Has the        |    |    |      |            |            |       |
| employee been  |    |    |      |            |            |       |
| exposed to     |    |    |      |            |            |       |
| traumatic      |    |    |      |            |            |       |
| noise (e.g.    |    |    |      |            |            |       |
| gunfire,       |    |    |      |            |            |       |
| explosion) in  |    |    |      |            |            |       |
| past six       |    |    |      |            |            |       |
| months that    |    |    |      |            |            |       |
| the employee   |    |    |      |            |            |       |
| considers      |    |    |      |            |            |       |
| loud:  Yes   |    |    |      |            |            |       |
| No If yes,     |    |    |      |            |            |       |
| please         |    |    |      |            |            |       |
| describe:      |    |    |      |            |            |       |
| \_             |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| \_\_           |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
+----------------+----+----+------+------------+------------+-------+
| Has the        |    |    |      |            |            |       |
| employee had   |    |    |      |            |            |       |
| current or     |    |    |      |            |            |       |
| past military  |    |    |      |            |            |       |
| service noise  |    |    |      |            |            |       |
| exposures:    |    |    |      |            |            |       |
| Yes  No If    |    |    |      |            |            |       |
| yes, please    |    |    |      |            |            |       |
| describe:      |    |    |      |            |            |       |
| \_             |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
| \_\_\_\_\_\_\_ |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Is the         |    |    |      |            |            |       |
| employee right |    |    |      |            |            |       |
| or             |    |    |      |            |            |       |
| left-handed?  |    |    |      |            |            |       |
| right  left   |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Does the       |    |    |      |            |            |       |
| employee use   |    |    |      |            |            |       |
| hearing        |    |    |      |            |            |       |
| protective     |    |    |      |            |            |       |
| devices:  Yes |    |    |      |            |            |       |
|  No. If yes,  |    |    |      |            |            |       |
| what type?    |    |    |      |            |            |       |
| Muffs  Plugs  |    |    |      |            |            |       |
|  Both.        |    |    |      |            |            |       |
| Specify the    |    |    |      |            |            |       |
| listed NRR     |    |    |      |            |            |       |
| \_\_\_\_\      |    |    |      |            |            |       |
| _\_\_\_\_\_dB, |    |    |      |            |            |       |
| and the        |    |    |      |            |            |       |
| adjusted NRR   |    |    |      |            |            |       |
| \_\_\_\_\_\    |    |    |      |            |            |       |
| _\_\_\_\_\_dB. |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Is the         |    |    |      |            |            |       |
| attenuation    |    |    |      |            |            |       |
| afforded       |    |    |      |            |            |       |
| appropriate    |    |    |      |            |            |       |
| for the noise  |    |    |      |            |            |       |
| level and      |    |    |      |            |            |       |
| frequencies,   |    |    |      |            |            |       |
| i.e., reduces  |    |    |      |            |            |       |
| the ambient    |    |    |      |            |            |       |
| noise below 85 |    |    |      |            |            |       |
| dB?  Yes  No |    |    |      |            |            |       |
| If no, what is |    |    |      |            |            |       |
| recommended?   |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| What is the    |    |    |      |            |            |       |
| condition of   |    |    |      |            |            |       |
| the PPE?       |    |    |      |            |            |       |
|                |    |    |      |            |            |       |
| Is it worn     |    |    |      |            |            |       |
| correctly ?    |    |    |      |            |            |       |
+----------------+----+----+------+------------+------------+-------+

**EMPLOYEE NOISE EXPOSURE QUESTIONNAIRE ( page 2)**

+------------------+---+----------+-------------------+----+----------+
| Occupational     | Y | Exposure | Non-occupational  | Y  | Exposure |
| Exposures        | e | Duration | Exposures         | es | Duration |
|                  | s |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+
| Grinding         |   |          | Hunting/shooting  |    |          |
+------------------+---+----------+-------------------+----+----------+
| Power Tool       |   |          | Power tool        |    |          |
| Operation        |   |          | operation         |    |          |
+------------------+---+----------+-------------------+----+----------+
| Chain saws       |   |          | Chain saws        |    |          |
+------------------+---+----------+-------------------+----+----------+
| Grass Cutting    |   |          | Grass cutting     |    |          |
+------------------+---+----------+-------------------+----+----------+
| Generators/pumps |   |          | Model airplane    |    |          |
|                  |   |          | flying            |    |          |
+------------------+---+----------+-------------------+----+----------+
| Compressors      |   |          | Powered           |    |          |
|                  |   |          | watercraft        |    |          |
|                  |   |          | operation         |    |          |
+------------------+---+----------+-------------------+----+----------+
| Metal working    |   |          | Metal working     |    |          |
| machines         |   |          | machines          |    |          |
+------------------+---+----------+-------------------+----+----------+
| Woodworking      |   |          | Woodworking       |    |          |
+------------------+---+----------+-------------------+----+----------+
| Impact           |   |          | Air driven tools  |    |          |
| equipment/air    |   |          |                   |    |          |
| driven           |   |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+
| Earth moving     |   |          | Farm machinery    |    |          |
| equipment        |   |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+
| Hammering        |   |          | Hammering         |    |          |
| activities       |   |          | activities        |    |          |
+------------------+---+----------+-------------------+----+----------+
| Shop vacuum      |   |          | Shop vacuum       |    |          |
+------------------+---+----------+-------------------+----+----------+
| Exp              |   |          | Scuba diving      |    |          |
| losions/firearms |   |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+
| High pressure    |   |          | Loud              |    |          |
| discharges       |   |          | music/concerts    |    |          |
+------------------+---+----------+-------------------+----+----------+
| Ventilation      |   |          | Flying,           |    |          |
| systems          |   |          | non-commercial    |    |          |
+------------------+---+----------+-------------------+----+----------+
| Compacting       |   |          | Contact sports    |    |          |
| equipment        |   |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+
| Communications   |   |          | Motor vehicle     |    |          |
| equipment        |   |          | racing            |    |          |
+------------------+---+----------+-------------------+----+----------+
| Other            |   |          | Other             |    |          |
+------------------+---+----------+-------------------+----+----------+
| Additional       |   |          |                   |    |          |
| Comments:\_\_\_  |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| \_\_\_\_\_       |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+
| Based on field   |   |          |                   |    |          |
| review, SHSD ** |   |          |                   |    |          |
| Recommends,     |   |          |                   |    |          |
| Does not         |   |          |                   |    |          |
| recommend** a    |   |          |                   |    |          |
| comprehensive    |   |          |                   |    |          |
| noise            |   |          |                   |    |          |
| evaluation.      |   |          |                   |    |          |
| Evaluation       |   |          |                   |    |          |
| scheduled for:   |   |          |                   |    |          |
| Date\_           |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+
| **Historical     |   |          |                   |    |          |
| exposure         |   |          |                   |    |          |
| monitoring       |   |          |                   |    |          |
| data:**          |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| Area sound level |   |          |                   |    |          |
| at work position |   |          |                   |    |          |
| \_\_\_\_\_dBA,   |   |          |                   |    |          |
| Personal         |   |          |                   |    |          |
| exposure         |   |          |                   |    |          |
| \_\_\_\_\_dBA as |   |          |                   |    |          |
| 8 hr. TWA,       |   |          |                   |    |          |
| Dat              |   |          |                   |    |          |
| e:\_\_\_\_\_\_\_ |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| Area sound level |   |          |                   |    |          |
| at work position |   |          |                   |    |          |
| \_\_\_\_\_dBA,   |   |          |                   |    |          |
| Personal         |   |          |                   |    |          |
| exposure         |   |          |                   |    |          |
| \_\_\_\_\_dBA as |   |          |                   |    |          |
| 8 hr. TWA,       |   |          |                   |    |          |
| Dat              |   |          |                   |    |          |
| e:\_\_\_\_\_\_\_ |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| Area sound level |   |          |                   |    |          |
| at work position |   |          |                   |    |          |
| \_\_\_\_\_dBA,   |   |          |                   |    |          |
| Personal         |   |          |                   |    |          |
| exposure         |   |          |                   |    |          |
| \_\_\_\_\_dBA as |   |          |                   |    |          |
| 8 hr. TWA,       |   |          |                   |    |          |
| Dat              |   |          |                   |    |          |
| e:\_\_\_\_\_\_\_ |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| C                |   |          |                   |    |          |
| omments:\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| \_\_\_\_\_       |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+
| **Current        |   |          |                   |    |          |
| Exposure         |   |          |                   |    |          |
| Evaluation       |   |          |                   |    |          |
| Results:**       |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| Area sound level |   |          |                   |    |          |
| at work position |   |          |                   |    |          |
| \_\_\_\_\_dBA,   |   |          |                   |    |          |
| Personal         |   |          |                   |    |          |
| exposure         |   |          |                   |    |          |
| \_\_\_\_\_dBA as |   |          |                   |    |          |
| 8 hr. TWA,       |   |          |                   |    |          |
| Dat              |   |          |                   |    |          |
| e:\_\_\_\_\_\_\_ |   |          |                   |    |          |
| ACGIH 8 Hour     |   |          |                   |    |          |
| Dose \_\_\_\_\_  |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| Area sound level |   |          |                   |    |          |
| at work position |   |          |                   |    |          |
| \_\_\_\_\_dBA,   |   |          |                   |    |          |
| Personal         |   |          |                   |    |          |
| exposure         |   |          |                   |    |          |
| \_\_\_\_\_dBA as |   |          |                   |    |          |
| 8 hr. TWA,       |   |          |                   |    |          |
| Dat              |   |          |                   |    |          |
| e:\_\_\_\_\_\_\_ |   |          |                   |    |          |
| ACGIH 8 Hour     |   |          |                   |    |          |
| Dose \_\_\_\_\_  |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| Area sound level |   |          |                   |    |          |
| at work position |   |          |                   |    |          |
| \_\_\_\_\_dBA,   |   |          |                   |    |          |
| Personal         |   |          |                   |    |          |
| exposure         |   |          |                   |    |          |
| \_\_\_\_\_dBA as |   |          |                   |    |          |
| 8 hr. TWA,       |   |          |                   |    |          |
| Dat              |   |          |                   |    |          |
| e:\_\_\_\_\_\_\_ |   |          |                   |    |          |
| ACGIH 8 Hour     |   |          |                   |    |          |
| Dose \_\_\_\_\_  |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| Comments         |   |          |                   |    |          |
| (include         |   |          |                   |    |          |
| information      |   |          |                   |    |          |
| regarding impact |   |          |                   |    |          |
| and peak         |   |          |                   |    |          |
| exposures)       |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| **** Include    |   |          |                   |    |          |
| employee in the  |   |          |                   |    |          |
| similar exposure |   |          |                   |    |          |
| group (SEG)      |   |          |                   |    |          |
| specified        |   |          |                   |    |          |
| as\_\_\_\_\_\_   |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| **** No SEG     |   |          |                   |    |          |
| exists for this  |   |          |                   |    |          |
| job activity.    |   |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+
| **               |   |          |                   |    |          |
| Determination:** |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| SHSD determined  |   |          |                   |    |          |
| that the subject |   |          |                   |    |          |
| employee **     |   |          |                   |    |          |
| does,  does     |   |          |                   |    |          |
| not** have the   |   |          |                   |    |          |
| potential to be  |   |          |                   |    |          |
| exposed at or    |   |          |                   |    |          |
| above the 8 hr.  |   |          |                   |    |          |
| TWA ** standard |   |          |                   |    |          |
| of 85BA,  peak  |   |          |                   |    |          |
| exposures \>140  |   |          |                   |    |          |
| dB** on one or   |   |          |                   |    |          |
| more days per    |   |          |                   |    |          |
| week. The        |   |          |                   |    |          |
| employee ** is, |   |          |                   |    |          |
|  is not**       |   |          |                   |    |          |
| required to be   |   |          |                   |    |          |
| in the hearing   |   |          |                   |    |          |
| conservation     |   |          |                   |    |          |
| program on the   |   |          |                   |    |          |
| basis of job     |   |          |                   |    |          |
| related noise    |   |          |                   |    |          |
| exposure.        |   |          |                   |    |          |
| Periodic noise   |   |          |                   |    |          |
| monitoring **   |   |          |                   |    |          |
| is,  is not**   |   |          |                   |    |          |
| required.        |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| Interviewer:     |   |          |                   |    |          |
| \_\_             |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| Date:            |   |          |                   |    |          |
| \_\_\_           |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
| \_\_\_\_\_\_\_\_ |   |          |                   |    |          |
|                  |   |          |                   |    |          |
| **IMPORTANT:     |   |          |                   |    |          |
| Send copy to     |   |          |                   |    |          |
| Occupational     |   |          |                   |    |          |
| Medicine Clinic  |   |          |                   |    |          |
| & SHSD Safety    |   |          |                   |    |          |
| Engineering      |   |          |                   |    |          |
| Group when       |   |          |                   |    |          |
| investigation is |   |          |                   |    |          |
| in response to   |   |          |                   |    |          |
| an STS.**        |   |          |                   |    |          |
+------------------+---+----------+-------------------+----+----------+