Centers for Disease Control

and Prevention

National Institute for Occupational 

Safety and Health

Using Total Worker Health® Concepts 

to Address Hearing Health

Description of Noise 

Exposure 

Hearing health is important in all stages of life, and many factors influence 

hearing health. Each individual is on 

a personal “hearing health trajectory” 

– a lifelong path in which genetic, biological, behavioral, environmental, 

and social factors over time contribute 

to hearing ability as life progresses [Davis et al. 2016]. This trajectory begins at 

conception and is influenced by health, 

socio-economic factors, disease, genetics, injury, access to health care, lifestyle choices (e.g., smoking, diet), recreational activities (e.g., motorcycling, 

concerts, loud sports), environmental 

conditions, and occupational exposures 

[Davis et al. 2016]. These elements interact to influence how well one will be 

able to hear as he or she ages. Although 

some of the factors are difficult (if not 

impossible) to control (like ageing itself), many can be modified to reduce 

the risk of hearing loss. These include 

disease prevention, good nutrition and 

physical fitness, limiting exposures to 

hazards, and participating in hearing 

loss prevention programs at work. A 

comprehensive, integrated approach to 

health is needed to effectively prevent 

or reduce the risk of auditory disorders 

Summary

Exposure to hazardous types and 

levels of noise is common both at 

work and in daily life. Therefore, 

while protecting workers on the 

job is very important, it is also important to raise awareness and encourage protective behavior outside 

of work. In addition, other risk factors—both on and off the job—can 

interact with noise to increase or decrease risk. Through its Total Worker Health® (TWH) Program, the National Institute for Occupational Safety and Health (NIOSH) recommends 

an integrated approach to address the 

hearing health of workers. An integrated approach is a comprehensive 

consideration of risk factors intended 

to protect workers from work-related 

injury and illness and help them advance their overall health and wellbeing, on and off the job. The approach includes addressing exposures at work, environmental factors, 

and personal factors [NIOSH 2018c]. 

This Workplace Solutions document 

focuses on the application of TWH 

concepts to promote better hearing 

health and reduce the risks associated 

with noise exposure.

such as hearing loss, tinnitus (ringing 

in the ears), and hyperacusis (abnormal 

sensitivity to sound). 

Among the risk factors we can control, the single most important is exposure to loud noise. Exposures are not 

restricted to the workplace; exposures 

occur throughout our lifetime in our 

communities and home environment. 

Health Effects of 

Noise Exposure 

In addition to hearing loss, overexposure 

to noise can cause tinnitus and hyperacusis. Noise is a nonspecific biological 

stressor; as such, it can cause reactions 

in other bodily system as well. Exposure 

to high noise levels can cause adverse 

changes in blood pressure and chemistry [Themann et al. 2013a]. Noise and 

hearing loss have been associated with 

a wide variety of health problems, ranging from stress and hypertension to depression. Symptoms such as headaches, 

irritability, increased tension, fatigue, 

sleep disorders, and cardiovascular disease have also been described. Noise can 

sometimes lead to performance decrements (especially for complex or simultaneous tasks) and has been associated 

with increased accident risk and absen-
2

teeism [NIOSH 2011; Themann et al. 2013a]. Implementing 

strategies that minimize noise exposure could have positive 

health effects beyond hearing health.

Exposure Limits

In the United States, occupational regulations and standards 

were established to protect workers against the health effects 

of exposure to hazardous substances and agents when certain values (or limits) are reached. Note that the exposure 

limits for noise have been established to prevent hearing 

loss caused by repeated exposure to excessive noise. Other 

health effects (e.g., stress, cardiovascular disease) may occur 

at lower levels, and other risk factors (e.g., ototoxic exposures, overall physical health) may alter one’s personal hearing loss risk. 

OSHA Permissible Exposure Limit 

The Occupational Safety and Health Administration (OSHA) 

permissible exposure limit (PEL) for noise is 90 dBA, and 

the action level (AL) is 85 dBA, both as an 8-hour TWA using a 5-dB exchange rate [Occupational Noise Exposure 29 

CFR 1910.95]. This means that hearing protection, administrative controls, and annual monitoring are required when 

exposures exceeed the AL, and engineering controls are required when exposures exceed the PEL. The OSHA occupational noise standard also mandates that exposures to 

impact or impulsive noise not exceed 140 dB peak sound 

pressure level.*

*The MSHA rule (30 CFR Part 62) is similar to OSHA’s.

NIOSH Recommended Exposure Limit 

NIOSH establishes recommended exposure limits (RELs) 

for various hazards on the basis of the best available science 

and practice. The NIOSH REL for noise is 85 decibels, using 

the A-weighted frequency response (often written as dB(A) 

or dBA) averaged over an 8-hour workday—usually referred 

to as the time-weighted average (TWA). The A-weighting of 

noise levels is used to provide a rating that indicates the injurious effects of noise on human hearing. Exposures at or 

above the REL are considered hazardous [NIOSH 1998].

NIOSH recommends a 3 dB exchange rate, or time-intensity 

trade-off, for occupational noise exposure. This means that 

for every 3 dB increase in exposure level, the allowable exposure time is halved; for example, when the noise level increases from 85 dBA to 88 dBA, the allowable exposure time 

decreases from 8 hours to 4 hours. The 3 dB exchange rate 

is based on the equal energy principle: with every 3 dB increase in noise level, the energy is doubled and therefore the 

exposure time is halved. Table 1 shows allowable exposure 

times for various noise levels under the NIOSH REL.

Exposure limits are not always set at levels that will protect 

the entire exposed population. In setting the REL for noise, 

NIOSH acknowledged that 8% of the noise-exposed population could still develop a hearing loss if exposed over a 40-

year working lifetime to average daily noise levels of 85 dBA. 

Because individual susceptibility to noise exposure varies, 

NIOSH recommends the use of hearing protection whenever noise levels exceed 85 dBA—regardless of exposure duration.

Photo by ©fotokostic/Getty Images
3

Table 1. Allowable exposure times 

under the NIOSH REL

Exposure level

Time to reach maximum 

daily allowable noise dose 

(per NIOSH REL)

85 dBA 8 hours

88 dBA 4 hours

91 dBA 2 hours

94 dBA 60 minutes

97 dBA 30 minutes

100 dBA 15 minutes

EPA

The United States Environmental Protection Agency (EPA) 

recommends maintaining environmental noises below 70 

dBA (averaged over 24 hours) to prevent hearing loss in 

the general population [EPA 1974]. This recommendation 

is based on evidence available at the time; EPA used the 

same scientific evidence and the same equal-energy rule that 

NIOSH used in setting its REL. Also like the NIOSH REL, 

the EPA assumed 40-year lifetime exposures in making its 

recommendations.

The difference between the NIOSH REL and the EPA recommendation for environmental noise exposures is due to 

several key factors. The NIOSH REL assumes an 8-hour exposure (during the workshift) with time for the ear to recover before the next exposure; the EPA limit is averaged over 

24 hours with no time between exposures. In addition, the 

NIOSH limit is based on exposure for 250 working days a 

year, whereas the EPA limit is based on exposures for 365 

days a year. Finally, the NIOSH REL is set at a level that will 

protect 92% of workers, whereas the EPA limit is set at a level that will protect 96% of the population [NIOSH 2016b].

WHO

The World Health Organization [WHO] also recommends 

that noise levels be maintained below 70 dBA for 24-hour 

exposures [WHO 1999] in order to prevent hearing impairment. Like NIOSH and EPA, the WHO recommendation incorporates a 3 dB equal energy time-intensity trade-off.

Research on Noise Exposure: 

Occupational Factors

Much of our understanding of noise-induced hearing loss 

comes from studies on the effects of noise at work, considering a working lifetime of up to 40 years [NIOSH 1998; 

ANSI/ASA 2013]. Occupational hearing loss is one of the 

most common work-related illnesses in the United States. 

According to the National Health Interview Survey, 24% of 

cases of hearing difficulty among the working population are 

attributable to workplace exposures [Tak and Calvert 2008].

Hearing loss is prevalent in many industries—both those 

traditionally associated with noise exposure (such as manufacturing, construction, and mining) as well as industries 

generally assumed to have minimal risk of noise exposure 

(such as real estate and health care) [Masterson et al. 2013, 

2015].

Many workers do not use hearing protection because they 

think it interferes with communication or warning signals. 

Other workers may adopt a fatalistic attitude and believe 

that hearing loss is inevitable or that management is not 

concerned about their hearing health [Morata et al. 2005].

Research on Noise Exposure: 

Environmental/Non-work Factors

Noise levels during some daily activities (for example, mowing the lawn or waiting for an approaching subway) and 

some recreational activities (such motorcycling or listening to a personal music player) can exceed 70 or even 85 

dBA. Some hobbies (such as hunting, target shooting, concerts, or setting off fireworks) can exceed 140 dB and are 

loud enough to trigger immediate auditory disorders. The 

NIOSH Hearing Loss and Prevention Topic Page [NIOSH 

2018b] shows the decibel levels from various daily activities 

and other noise sources. CDC Vital Signs and the CDC National Center for Environmental Health [CDC 2017, 2019] 

also have information about decibel levels and sources of potential hearing loss.

Studies of populations who are not exposed to noise at work 

show a much lower risk of hearing difficulties than populations exposed at work [Masterson et al. 2016], and some 

studies show no group effects for those exposed to recreational noise or music [Neitzel et al. 2004; Dehnert et al. 

2015; Williams et al. 2015]. However, certain individuals 

can still experience adverse hearing effects from recreational noise exposure [Flamme et al. 2012; Kardous and Morata 

2010]. Susceptibility is determined by each person’s “hearing 

health trajectory” and by how loud and how often a person is 

exposed to hearing hazards. Moreover, since the duration of 

noise exposure influences risk, total noise exposure (including both work and non-work exposures) must be considered 

in efforts to prevent negative effects from noise. Since identifying those who are more susceptible is not possible, it is important to understand and manage risks. 
4

What is Total Hearing Health? 

Expanding occupational hearing conservation initiatives 

beyond the workplace would help prevent the adverse effects of noise; this includes integrating hearing loss prevention activities into clinical practice and community outreach programs. Regardless of occupation, nearly everyone 

will encounter hazardous noise throughout their lifetime. 

Raising awareness of noise levels outside of work will help 

ensure that overall daily noise exposures (not just daily 

workplace exposures) are safe. In addition, noise can interact with other risk factors to affect overall hearing health. 

For example, early noise exposures may affect quality of 

life as a person ages, while age may exacerbate the effect of 

workplace exposures. 

Therefore, the scope of efforts to address exposure should 

be broadened to include multiple sources of noise. In addition, hearing difficulties are not the only health outcomes of 

noise exposure. Reducing the prevalence of hearing loss requires a comprehensive approach. Addressing exposures to 

noise could have benefits to health, safety, and wellbeing that 

go beyond the prevention of hearing loss, tinnitus, and hyperacusis. 

Prevention efforts – both at and away from work – should 

address possible barriers. Adopting Total Hearing Health 

concepts conveys a strong message to workers that management is committed to promoting better hearing health and 

reducing adverse health risks from noise both at work and 

in everyday life.

Total Worker Health®: An 

Integrated Approach

Total Hearing Health is based on Total Worker Health®. Total Worker Health approaches are defined as policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and 

illness prevention efforts in order to advance employee wellbeing. Comprehensive practices and policies that take into 

account the work environment (both physical and organizational), while also addressing personal health risk factors, 

are more effective in preventing disease and promoting safety and health than each approach taken separately [NIOSH 

2018c; Sorensen et al. 2013]. 

Controlling exposures to occupational hazards is the responsibility of employers and is the fundamental method of protecting workers’ health. To protect workers’ hearing health means to reduce noise at its source to the extent 

possible through methods such as engineering controls and 

Buy Quiet programs [NIOSH 2014, 2018a]. However, while 

employers are required to protect workers from harmful 

working conditions, the Total Worker Health® approach encourages organizations to advance worker well-being more 

broadly. Total Worker Health strategies emphasize organization-level interventions over individual controls and strategies (including PPE), concentrating on workplace policies, programs, and practices that address the job design and 

workplace conditions (such as workload, management practices, and work schedules and shifts that could all play a part 

in reducing exposure to hazards.)

The following case studies illustrate how Total Hearing 

Health concepts are being applied in workplaces and communities.

Case Study 1

24-Hour Protection

The 3M manufacturing plant in Hutchinson, Minnesota 

addresses non-occupational noise exposures encountered 

by their workforce by promoting “24-Hour Protection” 

[NIOSH 2015c]. In their region, hunting is a favorite sport, 

and exposure to recreational firearm impulse noise is common among their workforce. In view of this, 3M Hutchinson:

 Incorporates information about the unique auditory risks 

of firearm noise and hearing protectors specially designed 

for shooting sports in their annual hearing conservation 

training programs.

 Stocks earplugs specifically designed for shooting sports 

in the employee store at minimal cost to workers and 

their family members. 

 Promotes awareness campaignsreminding workers and their 

families to use hearing protection each fall and spring when 

hunting season opens.

Buy Quiet

To reduce workplace noise exposures, 3M implemented 

Buy Quiet [NIOSH 2014] principles, noise exposure assessments, and noise-reduction projects. As a result, noise exposures were so successfully reduced (12‒14 dBA across 24 

different areas and departments), that 199 of 203 employees 

were no longer required to be included in the 3M Alexandria 

Hearing Conservation Program. Both the Hutchinson and 

Alexandria 3M facilities received the Safe-in-Sound Award 

for Excellence in Hearing Loss Prevention in the Manufacturing Sector [CDC et al. 2018].

Case Study 2

Using participatory Total Worker Health® methods and tools, 

the Center for the Promotion of Health in the New England Workforce is developing a hearing health promotion 
5

intervention for transportation workers that promotes active worker participation in its development, implementation, and maintenance [Cavallari et al. 2017]. As a first step, 

transportation workers participated in a survey about hearing health, overall workplace safety and health climate, and 

the use of hearing protection at home. Of 271 participants, 

only 94 (35%) had been tested within the last 2 years. Hearing loss diagnosis was reported by 32 (13%) participants; 148 

(56%) report ringing in ears and/or muffled hearing following loud noise exposure. For the next phase of the project, 

workers and a steering committee (with management and 

union representation) will design and implement noise and 

hearing interventions tailored to their needs. These interventions include a safety leadership training for supervisors, 

a noise hazard scheme that allows worker to easily assess the 

noise level of a task/equipment and choose the right hearing 

protection device, and a video training for workers emphasizing the OSHA Hearing Conservation Program required 

elements as well as the noise hazard scheme and how to provide coworker support for the use of hearing protectors.

Recommendations for Employers: 

Incorporating Total Hearing Health 

Concepts into Workplace Safety 

and Health Programs [NIOSH 2014, 

2015a,b; 2016a,b, 2018a,b,c, 

2019; Schulte et al. 2012, 2015; 

Sorensen et al. 2013].

 Follow the hierarchy of controls to reduce noise exposure. 

Eliminate or substitute the noise source if possible, or use 

engineering controls to reduce the noise level.

 Implement a Buy Quiet program to move toward eliminating or substituting sources of hazardous noise. Establish design specifications regarding noise levels to be 

followed when purchasing equipment, and include equipment noise specifications in procurement documents. 

 Encourage workers to get to know their noise exposures 

both on and off the job. Advances in technology have 

made it possible for anyone to monitor their own noise 

exposures using inexpensive sound level meters or smart 

phone apps (e.g., the NIOSH sound level meter app. The 

topic page includes information about how to interpret 

results). Discuss sound measurement apps at safety meetings or loan out inexpensive sound level meters to raise 

awareness about hazardous noise.

 When noise level measuring equipment or apps are not 

available, train workers to identify hazardous noise levels by using the following rule: if you have to raise your 

voice to be heard by someone three feet (an arm’s length) 

away, the level is probably loud enough to put your hearing at risk.

 Ensure that programs promoting hearing health and 

hearing loss prevention have the commitment of organizational leadership, support from all levels of management, and worker participation and input. Establishing 

a noise control program can be a good demonstration of 

organizational commitment to safer noise levels.

 Involve workers and labor representatives in designing 

and implementing procedures and practices to reduce 

noise exposure and promote better hearing health practices.

 Include health education about the effects of noise exposure and ways to prevent any negative effects. In addition 

to disseminating written information, host regular awareness sessions on hearing health.

 Promote the importance of healthful living and overall 

hearing health, and let workers know what resources are 

available to help them.

 Counsel workers about hearing risks among their family 

members. Establishing safe listening habits in youth can 

carry over into safe work habits when the children reach 

working age. 

 Train workers in the proper use of hearing protectors.

 Make hearing protectors available during workshifts and 

also for off-the-job noise exposures. Educate workers 

about non-occupational exposures and encourage them 

to use hearing protection when they are exposed to noise 

away from work. 

 Supply hearing protection for community events that may 

involve loud noise or loud music exposures or other risks 

to hearing. Supporting hearing loss prevention efforts in 

the community reinforces hearing loss prevention messages at work.

 Ensure that the program includes regular audiometric 

testing.

 Routinely evaluate the program and make adjustments as 

needed.

Recommendations for Workers: 

Protecting Hearing Health on and 

off the Job [NIOSH 1996, 2015a,b, 

2019]

 Know your exposure. Overexposure to excessively loud 

noises can cause irreversible damage to your hearing. Use 

an inexpensive sound level meter or a sound measuring 

app (such as the NIOSH sound level meter app) to check 

noise levels. 
6

 At work, take training on protecting your hearing and on 

wearing hearing protectors when needed, both during the 

workshift and for off-the-job noise exposures.

 Consult with event organizers or use crowd-sourcing 

apps or Internet searches to find information about noise 

levels associated with places you go or activities you do. 

Monitor how much time you devote to these activities. 

 When using headphones, WHO [1999] recommends limiting exposure to 1 hour per day at 85 dB.

 Remember the following rule for identifying hazardous 

noise levels when a sound measuring device or app is not 

available: if you have to raise your voice to be heard by 

someone three feet (an arm’s length) away), the noise level is too loud.

 Move around venues to find quieter spots. Locations that 

are farther away from the noise source and reflective surfaces such as walls may be quieter.

 Consider noise levels when buying tools, appliances, and 

other items for your home or hobbies. Noise levels may be 

provided on the product packaging or in online specifications. Consumer organizations also publish noise ratings 

for some types of products.

 Exposure time also contributes to risk. Take breaks in quieter areas. Limit your time in noise (from sports, transportation, firearms, etc.). It all adds up.

 Wear a hearing protector that you find comfortable each 

and every time you are around loud noise. Check the fit 

by cupping your hands over your ears; if you hear changes in sound with your hands over the protectors, the hearing protectors may not be fit properly. 

 Have your hearing tested regularly. If you experience any 

auditory symptoms (such as ringing in your ears, a feeling 

that your ears are “full,” or “muffling” of sounds) for more 

than 24 hours, have your hearing checked as soon as possible. Tinnitus and temporary changes in hearing might 

be an early sign of permanent damage.

 Practice healthful lifestyle choices, such as good nutrition 

and exercise. Your general health can affect your hearing 

health.

Recommendations for Hearing 

Health Clinicians: Incorporating 

Total Hearing Health into Clinical 

Practice [NIOSH 2015a,b; 2016c; 

2018a,b,c].

 Obtain hearing risk histories and counsel patients about 

prevention. Include questions about exposures to noise 

and ototoxic agents (drugs, chemicals) both at work and 

away from work as a routine part of patient hearing history. Ask specific questions about hobbies and other recreational activities that may increase hearing risk.†

 Expand the test battery for at-risk patients to look for evidence of early hearing changes. Otoacoustic emissions, 

extended high frequency audiometry, speech in noise 

testing, and some parameters of acoustic reflex and auditory brainstem response tests may sometimes provide evidence of early hearing changes before they are evident on 

the pure tone audiogram [Themann et al. 2013b].

 Encourage patients to know their noise exposure levels – 

for example, by using sound measurement tools (such as 

the NIOSH sound level meter app) or checking apps or 

other resources that report noise levels for specific places or activities.

 Counsel patients to adopt strategies that protect hearing 

health, including avoiding exposures, reducing exposure 

times, and using hearing protection.

 Provide hearing protector selection and fitting services. 

Inform your patients about all types of hearing protection 

devices and keep a varied supply in stock. Help noise-exposed patients select appropriate hearing protection, in 

view of their noise exposures as well as comfort and communication needs. Hearing protector fit-testing systems 

are readily available and suitable for clinical use and ensure that patients are fitting the device properly and receiving sufficient noise reduction.

 Create, support, or participate in campaigns that promote 

hearing health. Conduct hearing screenings at health 

fairs, visit schools to discuss hearing health, and measure 

output levels of personal listening devices. Many organizations have materials that can help raise awareness about 

the importance of preserving hearing:

— National Institute on Deafness and Other Communication Disorders (NIDCD, NIH). It’s a Noisy 

Planet campaign: https://www.noisyplanet.nidcd.

nih.gov/

— Department of Defense Hearing Center of Excellence: https://hearing.health.mil/Resources/Audioand-Print-Materials

†

For guidelines about questions, consult the following:

Johnson TA, Cooper S, Stamper GC, Chertoff M [2017]. Noise exposure 

questionnaire: A tool for quantifying annual noise exposure. J Am Acad 

Audiol 28(1):14-35. doi: 10.3766/jaaa.15070

Morata TC, Little MB [2002]. Suggested guidelines for studying the combined effects of occupational exposure to noise and chemicals on hearing. 

Noise Health 4(14):73-87 

The American Speech Language Hearing Association has recommendations for collecting a hearing history.
7

— Dangerous Decibels. Though originally designed 

for children, these materials have been adapted for 

adults and been translated into several languages: 

http://dangerousdecibels.org/

— American Speech Language Hearing Association. 

Listen to Your Buds campaign: https://www.asha.

org/buds/

— Sight and Hearing Association: http://www.sightandhearing.org/Services/NoisyToysList©.aspx

Acknowledgments

This document was prepared by Christa L. Themann and 

Thais Morata of the Division of Field Studies and Engineering (DFSE), and Susan Afanuh of the Division of Science 

Integration, National Institute for Occupational Safety and 

Health. Subject matter expert review was provided by the 

DFSE Audiology Branch, the NIOSH Total Worker Health® 

team, and the National Center for Environmental Health of 

the Centers for Disease Control and Prevention.

Suggested Citation

NIOSH [2019]. Using Total Worker Health® concepts to address hearing health. By Themann CL, Morata T, Afanuh 

S. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, 

DHHS (NIOSH) Publication No. 2019-155, https://doi.

org/10.26616/NIOSHPUB2019155

References

ANSI/ASA [2013] Acoustics - Estimation of Noise-induced 

Hearing Loss - Part 1: Method for Calculating Expected 

Noise-induced Permanent Threshold Shift (a modified nationally adopted international standard S3.44-2016/Part 1 

/ ISO 1999:2013 (MOD).

ASLHA. Hearing loss – beyond early childhood. American 

Speech and Language Hearing Association. https://www.

asha.org/PRPSpecificTopic.aspx?folderid=8589935335&s

ection=Assessment

Cavallari J, Punnett L, Cherniack M, Henning R [2017]. 

HearWell: A Total Worker HealthTM approach to hearing 

conservation among transportation workers. Abstracts of 

the 2017 Expanding Research Partnerships: State of the 

Science Conference. University of Colorado and the National Institute for Occupational Safety and Health. http://

www.ucdenver.edu/academics/colleges/PublicHealth/research/centers/CHWE/Events/Documents/2017_State_

of_the_Science_Conference_Program.pdf

CDC [2017]. Vital signs: too loud! For too long! https://

www.cdc.gov/vitalsigns/hearingloss/infographic.html

CDC [2019]. Loud noise can cause hearing loss. https://

www.cdc.gov/nceh/hearing_loss/

CDC, NIOSH, NHCA, CAOHC [2018]. Safe in Sound: Excellence in Hearing Loss Prevention Award. http://www.

safeinsound.us/archive.html#threeM16

Davis A, McMahon CM, Pichora-Fuller KM, Russ S, Lin F, 

Olusanya BO, Chadha S, Tremblay KL [2016]. Aging and 

hearing health: the life-course approach. Gerontologist 

56(Suppl-2):S256–67. http://dx.doi.org/10.1093/geront/

gnw033

Dehnert K, Raab U, Perez-Alvarez C, Steffens T, Bolte G, 

Fromme H, Twardella D [2015]. Total leisure noise exposure and its association with hearing loss among adolescents. Int J Audiol 54(10):665–673. http://dx.doi.org/10.31

09/14992027.2015.1030510 

EPA [1974]. Information on levels of environmental noise 

requisite to protect public health and welfare with adequate margin of safety. EPA/ONAC 550/9-74-004. 2

Flamme GA, Stephenson MR, Deiters K, Tatro A, van Gessel D, Geda K, Wyllys K, McGregor K [2012]. Typical 

noise exposure in daily life. Int J Audiol 51(Suppl 1):S3–

11. http://dx.doi.org/10.3109/14992027.2011.635316

Kardous CA, Morata T [2010]. Occupational and recreational noise exposures at stock car racing circuits: An exploratory survey of three professional race tracks. Noise Contr 

Eng J 58(1):54–61. https://doi.org/10.3397/1.3270506

Masterson EA, Tak S, Themann CL, Wall DK, Groenewold 

MR, Deddens JA, Calvert GM [2013]. Prevalence of hearing loss in the United States by industry. Am J Ind Med 

56(6):670–81. http://dx.doi.org/10.1002/ajim.22082 

Masterson EA, Deddens JA, Themann CL, Bertke S, Calvert GM [2015]. Trends in worker hearing loss by industry 

sector, 1981-2010. Am J Ind Med 58(4):392-401. http://

dx.doi.org/10.1002/ajim.22429 

Masterson EA, Themann CL, Luckhaupt SE, Li J, Calvert GM 

[2016]. Hearing difficulty and tinnitus among U.S. workers 

and non-workers in 2007. Am J Ind Med 59(4):290-300. 

http://dx.doi.org/10.1002/ajim.22565 

Morata TC, Themann CL, Randolph RF, Verbsky BL, Byrne 

DC, Reeves ER [2005]. Working in noise with a hearing 

loss: perceptions from workers, supervisors, and hearing 

conservation program managers. Ear Hearing 26:529–545. 

http://dx.doi.org/10.1097/01.aud.0000188148.97046.b8

Neitzel R, Seixas N, Goldman B, Daniell W. Contributions of 

non-occupational activities to total noise exposure of construction workers. Ann Occup Hyg 48(5):463–73. http://

dx.doi.org/10.1093/annhyg/meh041

NIOSH [1996]. Preventing occupational hearing loss: a 

practical guide. By Franks JR, Stephenson MR, Merry CJ. 

Cincinnati, OH: U.S. Department of Health and Human 
8

Services, Centers for Disease Control and Prevention, 

National Institute for Occupational Safety and Health, 

DHHS (NIOSH) Publication No. 96-110. https://doi.

org/10.26616/NIOSHPUB96110

NIOSH [1998]. Criteria for a recommended standard: occupational noise exposure. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for 

Occupational Safety and Health, DHHS (NIOSH) Publication No. 98‒126. https://doi.org/10.26616/NIOSHPUB98126

NIOSH [2011]. Reducing noise hazards for call and dispatch 

center operators. By Kardous C, Afanuh S. Cincinnati, OH: 

U.S. Department of Health and Human Services, Centers 

for Disease Control and Prevention, National Institute for 

Occupational Safety and Health, DHHS (NIOSH) Publication No. 2011-210. https://doi.org/10.26616/NIOSHPUB2011210

NIOSH [2014]. NIOSH Workplace Safety and Health Topic: Buy Quiet. https://www.cdc.gov/niosh/topics/buyquiet/default.html

NIOSH [2015a]. Reducing the risk of hearing disorders 

among musicians. Kardous C, Themann C, Morata T, 

Reynolds J, Afanuh S. Cincinnati, OH: U.S. Department of 

Health and Human Services, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-184. 

https://doi.org/10.26616/NIOSHPUB2015184 

NIOSH [2015b]. Total Hearing Health: Applying the Total Worker Health® concept to hearing loss prevention. By 

Themann CL, Morata T, Kardous C, Hudson H. Poster presented at the National Center for Rehabilitative Auditory 

Research (NCRAR) Conference. 

NIOSH [2015c]. Totally engaged in hearing loss prevention. 

By Meinke DK, Morata T. https://www.cdc.gov/niosh/

TWH/newsletter/TWHnewsv2n2.html#2

NIOSH [2016a]. Fundamentals of Total Worker Health® 

approaches: essential elements of advancing worker 

safety, health, and well-being. By Lee M, Hudson H, Richards R, Chang C. Cincinnati, OH: U.S. Department of 

Health and Human Services, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2017-112. 

https://doi.org/10.26616/NIOSHPUB2017112 

NIOSH [2016b]. NIOSH Science Blog: understanding noise 

exposure limits: occupational vs. general environmental 

noise. By Kardous C, Themann CL, Morata TC, Lotz WG. 

https://blogs.cdc.gov/niosh-science-blog/2016/02/08/

noise/

NIOSH [2016c]. NIOSH Workplace Safety and Health Topic: NIOSH sound level meter app. https://www.cdc.gov/

niosh/topics/noise/app.html

NIOSH [2018a]. NIOSH Workplace Safety and Health 

Topic: controls for noise exposure. https://www.cdc.gov/

niosh/topics/noisecontrol/default.html

NIOSH [2018b]. NIOSH Workplace Safety and Health Topic: noise and hearing loss prevention: hearing loss prevention programs. https://www.cdc.gov/niosh/topics/noise/

preventhearingloss/hearlosspreventprograms.html 

NIOSH [2018c]. NIOSH Workplace Safety and Health Topic: Total Worker Health. https://www.cdc.gov/niosh/twh/

totalhealth.html

NIOSH [2019]. NIOSH sound level meter app. https://www.

cdc.gov/niosh/topics/noise/app.html

Occupational noise exposure. 29 CFR 1910.95 

Schulte PA, Pandalai S, Wulsin V, Chun H [2012]. Interaction of occupational and personal risk factors in workforce 

health and safety. Am J Public Health 102(3):434–448. 

http://dx.doi.org/10.2105/AJPH.2011.300249

Schulte PA, Schill AL, Guerin RJ, Bhattacharya A, Cunningham TR, Pandalai SP, Eggerth D, Stephenson CM 

[2015]. Considerations for incorporating “well-being” 

in public policy for workers and workplaces. Am J Public Health 105(8):e31–e44. http://dx.doi.org/10.2105/

AJPH.2015.302616
9

For More Information 

More information about the NIOSH Total Worker Health® 

program can be found at https://www.cdc.gov/niosh/twh/

letsgetstarted.html

More information about noise and hearing loss prevention 

can be found at https://www.cdc.gov/niosh/topics/noise/

Find NIOSH products and get answers to workplace safety 

and health questions:

1-800-CDC-INFO (1-800-232-4636)

TTY: 1-888-232-6348

CDC/NIOSH INFO: cdc.gov/info | cdc.gov/niosh

Monthly NIOSH eNews: https://www.cdc.gov/niosh/enews/

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement 

of the sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these websites.

This document is in the public domain and may be 

freely copied or reprinted. NIOSH encourages all 

readers of the Workplace Solutions to make them 

available to all interested employers and workers.

As part of the Centers for Disease Control and Prevention, 

NIOSH is the Federal agency responsible for conducting 

research and making recommendations to prevent workrelated illnesses and injuries. All Workplace Solutions 

are based on research studies that show how worker exposures to hazardous agents or activities can be significantly reduced.

DOI: https://doi.org/10.26616/NIOSHPUB2019155

DHHS (NIOSH) Publication No. 2019-155

September 2019