Noise Exposure Health Surveillance Questionnaire Form
Please complete this questionnaire to help us monitor the effects of noise exposure in the workplace. Your responses will assist in identifying any hearing or ear-related symptoms and determining if follow-up is needed.
Full Name
*
First Name
Last Name
Employee ID or Work Reference (do not enter sensitive personal identifiers)
Job Role or Department
*
How often are you exposed to loud noise at work?
*
Daily
Several times a week
Occasionally
Rarely/Never
How would you rate the typical noise level in your work area?
*
1
2
3
4
5
Do you regularly use hearing protection (e.g., earplugs, earmuffs) when exposed to loud noise?
*
Always
Often
Sometimes
Never
Please indicate if you have experienced any of the following in the past 12 months:
*
Rows
Never
Occasionally
Frequently
Ringing or buzzing in ears (tinnitus)
1
2
3
Difficulty hearing conversations
4
5
6
Ear pain or discomfort
7
8
9
Feeling of fullness or pressure in ears
10
11
12
Have you noticed any recent changes in your hearing?
*
No
Yes, gradual change
Yes, sudden change
Do you have a history of hearing problems (not related to work)?
No
Yes
Not sure
Would you like to request a follow-up or further assessment regarding your hearing or noise exposure?
No
Yes
Submit
Should be Empty: