- The purpose for completing this form is to:
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.
- 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.
Enter your 9 digit ID number - (This can be found on your NCSU ID card)
MM slash DD slash YYYY
Please list your Department / Unit here
Please list your Section here
- 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
This field is for validation purposes and should be left unchanged.