Employee Noise Exposure Questionnaire

OSHA RECORDABLE QUESTIONNAIRE

PLEASE PRINT

Company: / City: / State:
Name: / DOB:
Job Title: / Noise Exposure Level (TWA):
o check here if unknown
Do you work with the majority of noise coming from one side? o Yes o No
If Yes, which side? o Left o Right / Do you wear a shoulder-mounted radio?
o Yes o No
If Yes, which side? o Left o Right
Have you ever had an explosion or blast to your ear? o Yes o No
If Yes, which side? o Left o Right / Have you ever had radiation or chemotherapy? o Yes o No
Explain:
Do you work around Industrial chemicals?
o Yes o No
If Yes, list name(s): / Do you work a second job? o Yes o No
Explain:
Do you work around loud noise?
o Yes o No / Type of Hearing Protector Used:
Average hours/day you work? / % of time used at work:

OFF-THE-JOB ACTIVITIES

Have you ever done the following: TIME PERIOD (years) USED HEARING PROTECTION?

Wood working / o No o Yes; From ______to ______o No o Yes
Metal working / o No o Yes; From ______to ______o No o Yes
Heavy equipment / o No o Yes; From ______to ______o No o Yes
Chain saws / o No o Yes; From ______to ______o No o Yes
Grinders/chippers / o No o Yes; From ______to ______o No o Yes
Air-driven tools / o No o Yes; From ______to ______o No o Yes
Motor sports / o No o Yes; From ______to ______o No o Yes
Farm machinery / o No o Yes; From ______to ______o No o Yes
Airplanes / o No o Yes; From ______to ______o No o Yes
Music (bands, concerts, headset) / o No o Yes; From ______to ______o No o Yes
Firearms which hand? R L / o No o Yes; From ______to ______o No o Yes
Leaf blower/trimmer / o No o Yes; From ______to ______o No o Yes

CURRENT CONDITIONS (Are you currently experiencing the following?)

PLEASE EXPLAIN

Ear pain / o No o Yes;
Ear drainage / o No o Yes;
Ear fullness or pressure / o No o Yes;
Sudden hearing loss / o No o Yes;
Severe ringing / o No o Yes;
Dizziness / o No o Yes;
Fluctuating hearing loss / o No o Yes;
Ear problem w/ protectors / o No o Yes;
Use a hearing aid / o No o Yes;
Seen a doctor for ears / o No o Yes;

HEALTH HISTORY (Have you ever had the following conditions?)

Please explain

High blood pressure / o No o Yes;
Diabetes / o No o Yes;
Parents with hearing loss / o No o Yes;
Meniere’s disease / o No o Yes;
Viral infection / o No o Yes;
Hearing loss as a child / o No o Yes;
High cholesterol / o No o Yes;
Smoking / o No o Yes;
Ear problems / o No o Yes;
Ear infections (discharge) / o No o Yes;
Ear surgery / o No o Yes;
Dizziness (vertigo) / o No o Yes;
Ear tumors / o No o Yes;
Hole in eardrum / o No o Yes;
Antibiotics for infection / o No o Yes;
Measles / o No o Yes;
Mumps / o No o Yes;
Meningitis / o No o Yes;
Scarlet fever / o No o Yes;
Kidney disease / o No o Yes;
Head injury / o No o Yes;

MEDICATIONS - Please list all current medications and dosage.

______

Do you think your hearing loss is caused by work noise? Explain…

______

Are there situations you find difficult to hear? Explain… ______

Additional Comments:

______

I acknowledge the above information is accurate to the best of my knowledge and authorize release of this information to my Employer for the purpose of determining OSHA recordability of my hearing loss.

Employee signature:______Date:______

Reviewed by:______Date:______