Noise Exposure Hazard Assessment – Environmental Health and Safety

The purpose for completing this form is to:

Determine if employees/staff need to be in NCSU’s Hearing Conservation Program and/or if noise level monitoring is needed,
Record your yearly exposure to noise
Comply with OSHA’s Hearing Conservation Standard.

Please complete this form to determine if the employee must be included in the University Hearing Conservation Program. A copy of the information you submitted will be sent to you. Please maintain it in your personnel or safety plan records.

Name*

First Last

Unity ID*

Employee ID #*

Enter your 9 digit ID number - (This can be found on your NCSU ID card)

Email*

Phone*

Date

Position / Job*

Employment Type*

Department / Unit*

Department / Unit OTHER

Please list your Department / Unit here

Section*

Section OTHER

Please list your Section here

Supervisor Information*

First Last Phone # Email

Program Administrator

First Last Email

Use*

Device / Process (*1)	Approx. Hrs / Day	Type of Protection (plugs, Muff, NPR(2,3)

Devices/Processes: List tools, machinery, process, or other circumstances where ear protection may be required at work.
Ear Plug Type: FOAM- soft and pliable roll between fingers, Plastic: rigid, no rolling needed, EAR Bands; Ear Muffs.
Noise Reduction Rating (NRR) of Ear Plugs and/or Muffs: See box or label for this information

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