IH Noise Single Monitoring Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Employee/Area

• Name of Employee/Area

• Employee Monitoring Photo

  Media

• Employee Working Photo

  Media

• Job Title

• Dosimeter Model

  Select Casella 350 Casella 35X Casella 360 Svantek 104

  • Casella 350
  • Casella 35X
  • Casella 360
  • Svantek 104

• Serial Number

  Select 772902 772904 772905 3735864 772901

  • 772902
  • 772904
  • 772905
  • 3735864
  • 772901

• Did you calibrate the dosimeter?

  Yes

  No

  N/A

• CEL Instruments Ltd. Acoustical Calibrator-CEL 110/2-Class 2C IEC 60492:2003-ANSI S1.40 1984-1000 Hz 114dB

• Serial Number

  Select 3591080 3591024 3591090 3591093 3591023

  • 3591080
  • 3591024
  • 3591090
  • 3591093
  • 3591023

• Did you calibrate the dosimeter?

  Yes

  No

  N/A

• CEL Instruments Ltd. Acoustical Calibrator-CEL 110/2-Class 2C IEC 60492:2003-ANSI S1.40 1984-1000 Hz 114dB

• Serial Number

  Select 3/112306 3/102271 3/102287 3/102252

  • 3/112306
  • 3/102271
  • 3/102287
  • 3/102252

• Did you calibrate the dosimeter?

  Yes

  No

  N/A

• CEL Instruments Ltd. Acoustical Calibrator-CEL 282-Class 2L IEC 942:1988-ANSI S1.40 1984-1000 Hz 114dB

• Serial Number

  Select 37261 37259 37263 37260 37262

  • 37261
  • 37259
  • 37263
  • 37260
  • 37262

• Did you calibrate the dosimeter?

  Yes

  No

  N/A

• SV-34 Acoustic Calibrator-Class 2 IEC 60942:2003-1000 Hz/114dB

• Start Time

  Date

• End Time

  Date

• Elapsed Time Including Breaks

• Employee wearing hearing protection?

  Yes

  No

  N/A

• Type of Hearing Protection

  Select Ear plugs Ear muffs Canal caps

  • Ear plugs
  • Ear muffs
  • Canal caps

• Hearing Protection

  Media

• Employee wearing additional PPE?

  Yes

  No

  N/A

• Eye Protection

• Gloves

• Steel-Toe Shoes

• Face Protection

• Respiratory Protection

• Head Protection

• Pre-Calibration Date

  Date

• Post-Calibration Date

  Date

• Calibration By

• Tasks Worked/Completed in Area

• Break Times

• OSHA TWA (dBA)

• ACGIH TWA (dBA)

• Additional Comments

• Additional Photos

  Media