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-AcademicAcademicDepartment / Unit*Facilities Services, Grounds and Building ServicesFacilities Services,Construction ServicesEnergy Systems, Building Maintenance & OperationsEnergy Systems, Utilities and EngineeringAthletics-Animal ScienceCrop & Soil SciencesMtn Hort Crops Research Ext CtrUniv Field LaboratoriesButner Beef Cattle Field LabMechanical and Aerospace EnginMinerals Research LaboratoryNonwovens InstituteCollege Of Vet MedicineHousing Facilities AdminEH & PS Div-Public SafetyOtherDepartment / Unit OTHER Please list your Department / Unit hereSection*Camp FacilitiesCommissioningConstruction ShopCentral Utility PlantControl ShopElectronicsElevatorsEnergy ManagementFCAP/WarrantyGroundsIn-House ConstructionLandscape and Construction ServicesPower SystemsShopsTurfUtility DistributionWaste Reduction and RecyclingZone ShopOtherSection OTHER Please list your Section hereSupervisor Information* First Last Phone # Email Program Administrator First Last Email Use*Device / Process (*1)Approx. Hrs / DayType 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 CAPTCHACommentsThis field is for validation purposes and should be left unchanged.