Workplace Noise Level Evaluation Form
Please complete the following sections of this form.
Basic Information
Item | Description |
Assessment Date: | [Month Day, Year] |
Department/Location: | |
Number of Employees: | |
Type of Work: | |
Shift Duration: | |
Noise Sources
Source of Noise | Description |
Machinery/Equipment: | [Soldering Stations, Conveyor Belts] |
Other Sources: | |
Noise Level Measurement
Measurement | Value (dB) | Time/Duration |
Average Noise Level: | [75] | [Throughout the shift] |
Peak Noise Level: | | |
Hearing Discomfort Reports:
Headaches/Concentration Issues:
Comments on Noise Levels:
[Employees find the noise level manageable but occasionally distracting.] |
Personal Protective Equipment (PPE)
PPE Provided:
Types of PPE:
PPE Usage Frequency:
Noise Control Measures
Current Measures:
Noise Control Suggestions:
PPE Improvements:
Other Recommendations:
Other Recommendations:
Evaluator's Signature:
[Your Name]
[Job Title]
[Month Day, Year]
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