Noise and Vibration Assessment Questionnaire Form
Use this questionnaire to assess noise and vibration exposure at your workplace or site. All responses help identify potential risks and improvements.
Site or Location Name
*
Your Role or Job Title
*
Which of the following best describes the primary sources of noise at this site?
*
Machinery or equipment
Vehicle traffic
Construction activities
Manual tools
Other
How many hours per day are you typically exposed to noise above normal conversation levels?
*
Please Select
Less than 1 hour
1-2 hours
2-4 hours
More than 4 hours
Rate the typical noise level at your work area.
*
1
2
3
4
5
Which of the following best describes the primary sources of vibration at this site?
*
Heavy equipment
Hand tools
Vehicle movement
Building/structural vibration
Other
How many hours per day are you typically exposed to vibration from tools, equipment, or vehicles?
*
Please Select
Less than 1 hour
1-2 hours
2-4 hours
More than 4 hours
Rate the typical vibration level at your work area.
*
1
2
3
4
5
Please indicate your agreement with the following statements about noise and vibration at your workplace.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Noise levels interfere with my ability to concentrate
1
2
3
4
5
Vibration causes discomfort or fatigue
6
7
8
9
10
I am aware of control measures for noise and vibration
11
12
13
14
15
Control measures are effective
16
17
18
19
20
Additional comments or observations about noise and vibration exposure at this site
Submit Assessment
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