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Noise Exposure Hazard Assessment
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
MM slash DD slash YYYY
Position / Job
*
Employment Type
*
Non-Academic
Academic
Department / Unit
*
Facilities Services, Grounds and Building Services
Facilities Services,Construction Services
Energy Systems, Building Maintenance & Operations
Energy Systems, Utilities and Engineering
Athletics-
Animal Science
Crop & Soil Sciences
Mtn Hort Crops Research Ext Ctr
Univ Field Laboratories
Butner Beef Cattle Field Lab
Mechanical and Aerospace Engin
Minerals Research Laboratory
Nonwovens Institute
College Of Vet Medicine
Housing Facilities Admin
EH & PS Div-Public Safety
Other
Department / Unit OTHER
Please list your Department / Unit here
Section
*
Camp Facilities
Commissioning
Construction Shop
Central Utility Plant
Control Shop
Electronics
Elevators
Energy Management
FCAP/Warranty
Grounds
In-House Construction
Landscape and Construction Services
Power Systems
Shops
Turf
Utility Distribution
Waste Reduction and Recycling
Zone Shop
Other
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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Comments
This field is for validation purposes and should be left unchanged.