Audiometric Test

• Name of Document:

  Monthly Audiometric Test Report

• Document No.

• Monitoring (Sample) Date:

  Date

• Prepared by:

  Select Christopher Cole Chuck Ayers James Shifflett Joseph Bailey Michael Dwyer Tom Chestnut Tom Manley Sudip Umachigi

  • Christopher Cole
  • Chuck Ayers
  • James Shifflett
  • Joseph Bailey
  • Michael Dwyer
  • Tom Chestnut
  • Tom Manley
  • Sudip Umachigi
• Drop Pin for GPS Work Activity Location:
  Address

• Personnel on site today: (Please list full names)

Hearing Conservation (see hearing conservation program for instructions)

• Project Name:

• Job Task:

• Activities Monitored:

• Major Noise Source(s):

  Pneumatic tools

  Sirens and horns

  Heavy equipment

  Vehicles

• PPE Used:

  Foam plugs

  Canal Caps

  Ear muffs

• Engineering Controls (Describe if applicable):

Sampling:

• Sampling Type

  AREA

  PERSONAL

• Sample Duration

  FULL

  PARTIAL

  ACTIVITY

  15 minute

  INSTANT

• Hours in Work Shift

  8

  10

  12

• (PEL) Permissible exposure limit:

• Shift PEL:

• Start time:

  Date

• Stop time:

  Date

• 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?

  YES

  NO

• 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:

  Sign

• Monitored employee signature:

  Sign

• Monitored employee signature:

  Sign

• Monitored employee signature:

  Sign

• Monitored employee signature:

  Sign

• Safety Manager Performing Sampling Test:

  Sign