Title Page

  • Client / Site

  • Location
  • Conducted on

  • Prepared by

Part A - Survey Paramaters

Survey Parameters

  • Date and time of survey

  • Click + to add persons involved

  • Employee
  • Reason for survey

  • Equipment used

Part B - Noise Survey and Exposure

Noise Survey and Exposure

  • Click + to add equipment producing noise

  • Equipment
  • Item Name

  • Location of equipment

  • Noise level (LAeq)*

  • EXPOSURE

  • Exposure duration

Part C - Control Measures

Control Measures

  • Are hearing protective equipment mandatory?

  • Can the noise source be eliminated?

  • Is additional maintenance required to reduce noise levels e.g. by lubrication, tightening, cleaning etc of equipment? (Reassess noise level after maintenance work is complete)

  • Can the equipment be modified to reduce noise at source, e.g. damping, silencers, baffles etc fitted?

  • Can inherently quieter components be selected e.g. slotted circular saw blades on woodworking equipment or quieter fans? (Reassess after replacement)

  • Can the equipment be Isolated i.e. removed to another location away from people at work?

  • Can the equipment be enclosed?

  • Is a noise refuge area needed?

  • Can absorptive material be used to deaden noise in the workspace?

  • Do staff need training or information on the noise risks?

  • Is health surveillance required?

Completion

Completion

  • Recommendation

  • Full Name and Signature of Assesor

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.