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:

• Yes

• No

Headaches/Concentration Issues:

• Yes

• No

Comments on Noise Levels:

[Employees find the noise level manageable but occasionally distracting.]

Personal Protective Equipment (PPE)

PPE Provided:

• Yes

• No

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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