Noise Exposure Monitoring Form
Employee Information
Name
First Name
Last Name
Job Title
Department
Date of Hire
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Monitoring Details
Date of Monitoring
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Monitoring Start Time & End Time
Hour Minutes
AM
PM
AM/PM Option
To
until
Hour Minutes
AM
PM
AM/PM Option
Location/Work Area
Noise Measurement
Type of Noise Measurement Device
Average Noise Level (dBA)
Peak Noise Level (dBA)
Personal Protective Equipment (PPE)
Hearing Protection Provided
Yes
No
Type of Hearing Protection
Engineering Controls
List of Engineering Controls in Place
e.g., barriers, soundproofing, machinery modifications
Employee Exposure
Duration of Exposure
Hour Minutes
Additional Comments/Notes
Recommendations
Suggestions for Noise Reduction
Follow-up Actions
Result & Report Attachments
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