TVA - Noise Dosimetry Data Sheet

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

TSP-310 Hearing Conservation (see records section of TSP310 for Appendix C Instructions)

• Monitoring (Sample) Date:

  Date

• Sample Number:

• Employee Name & ID:

• Similar Exposure Group (Job Title):

• Facility Name:

• Work Activity Location:

• Job Task:

• Activities Monitored:

• Major Noise Source(s):

• PPE used:

• Engineering Controls if applicable:

SAMPLING

• Sampling Type

  AREA

  PERSONAL

• Sample Duration

  FULL

  PARTIAL

  ACTIVITY

  15 minute

  INSTANT

• Hours in Work Shift

  8

  10

  12

• PEL:

• Shift PEL:

• START TIME:

  Date

• STOP TIME:

  Date

• SAMPLE LENGTH (minutes):

• START TIME:

  Date

• STOP TIME:

  Date

• SAMPLE LENGTH (minutes):

• START TIME:

  Date

• STOP TIME:

  Date

• SAMPLE LENGTH (minutes):

• Pre-Calibration:

• Post-Calibration:

• Sample Technician - Name & ID:

• SAMPLE RESULT DOSE:

• SAMPLE RESULT TWA:

• SUBMIT a Copy or Original of this Document to IH Section for inclusion in the IH database.

• NOTIFICATION of EMPLOYEE = or > 85dBa?

  YES

  NO

• IF YES, Then Notify Employee using this document, or Appendix D from TSP 310, Hearing Conservation or similar communication to meet notification intent.

• PER TSP-310 "TVA shall notify each employee exposed at or above an 8 hour time-weighted average (TWA) of 85 decibels of the results of the monitoring."

• MONITORED EMPLOYEE (print):

• MONITORED EMPLOYEE SIGNATURE:

  Sign

• When completed: Submit this document to Medical Records at the station or TVA facility medical office if available; if not available, then to Medical Records in Chattanooga at EBAY 1A-C.