Audit

Hearing Conservation (see hearing conservation program for instructions)

Project Name:

Job Task:

Activities Monitored:

Major Noise Source(s):

PPE Used:

Engineering Controls (Describe if applicable):

Sampling:

Sampling Type

Sample Duration

Hours in Work Shift

(PEL) Permissible exposure limit:

Shift PEL:

Start time:
Stop time:

Sample length (minutes):

Pre-Calibration:

Post-Calibration:

Sample result

Sample result (TWA):

SUBMIT a copy or original of this Document to Human Resources for inclusion in the employee file:

NOTIFICATION of EMPLOYEE = or > 85dBa?

IF YES, Then Notify Employee using this document, as part of the Hearing Conservation Program, or similar communication to meet notification intent.

W.C. Spratt, Inc. shall notify each employee exposed at or above an 8 hour time-weighted average (TWA) of 85 decibels of the results of the monitoring."

Signatures:
Monitored employee signature:
Monitored employee signature:
Monitored employee signature:
Monitored employee signature:
Monitored employee signature:
Safety Manager Performing Sampling Test:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.