Hearing Protection

Department:_____________________________ Supervisor______________________
Task Evaluated__________________________ Date___________________________
Building ________________________________ Location________________________
Name of Evaluator___________________________________________________________
 
I certify that on the above date I performed a hazard assessment of the above task. This document constitutes the certification of that hazard assessment. I understand that this document facilitates compliance to the hazard assessment requirements of OSHA 29 CFR 1910.132(d)(2), only. In addition, proper PPE selection, fitting, utilization and communication must be accomplished in accordance with other requirements of Subpart I.

Occasions may exist when employees are exposed to loud noise. Contact Occupational Health and Safety for a work place evaluation and additional information regarding hearing protection and a Hearing Conservation Program. (check box if applicable)

Part 1. HAZARD ASSESSMENT CHECKLIST

Job Questionnaire

Hazardous Activities

Required PPE
  Are your employees exposed to loud noise from machines, tools, music systems, etc? Machining, grinding, sanding, work near conveyors, pneumatic equipment, generator, ventilation fans, motors, punch and brake presses, etc. Earmuffs or ear plugs

Part 2. TRAINING GUIDE - Employees must be trained to know the following:

  • Why hearing protection is necessary, i.e., the workplace hazards that threaten their hearing
  • How the earplugs or earmuffs will protect them
  • The limitations of the hearing protection
  • When they must insert or wear the hearing protectors
  • How to adjust earmuff parts for a comfortable and effective fit or form the ear plugs to fit their ears
  • How to fit earmuffs when wearing glasses
  • How to clean and disinfect the hearing protection you provide for them

Part 3. VERIFICATION OF TRAINING
Personal Protective Equipment Assessment and Training

I have received and understand the material presented concerning a job hazard assessment and Personal Protective Equipment (PPE) requirements for this job assignment. My training included a discussion period covering the following points:
  • What PPE must be worn in this work place
  • When PPE must be worn
  • How to inspect PPE for wear and damage
  • How to put on, make fit, and take off PPE
  • What the limitations of the PPE are
  • How to properly store and clean PPE
  • How to properly dispose of the PPE

I have been afforded the opportunity to ask questions about the use of PPE and I have had a "hands on" exercise using this PPE properly.

Trainer/Supervisor____________________________ Date: _______________

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