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Industrial Hygiene Noise Dosimetry Survey Form

By Ann Carpenter,2014-06-29 15:29
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Industrial Hygiene Noise Dosimetry Survey Form

     Sample Date: INDUSTRIAL HYGIENE NOISE DOSIMETRY SURVEY FORM IH UIC: ___________ Activity: ______________________________________ UIC: ____________ Field Office: _____________________ Bldg./Hull #: _______________ Shop Location: _________________________ Shop Code/Name: _________________________________ Shift: 1. Day Frequency 1. Daily 2. 2-3/wk 3. Weekly 4. 2-3/mo Duration 1. 0-15 min 2. 15-30 min 3. 30-60 min 4. 1-2 hr of of 2. Eve. 3. Night 5. Monthly 6. 2-3/yr 7. Yearly 8. Special 5. 2-4 hr 6. 4-6 hr 7. 6-8 hr 8. > 8 hr Operation Operation

     1 2 3 4 5

    Personal Area Personal Area Personal Area Personal Area Personal Area Personal or Area

     Employee Name

     SEG

    Male Female Male Female Male Female Male Female Male Female Gender

    SSN/FN#/Badge #

     Job Title

    M C FN M C FN M C FN M C FN M C FN Mil/Civ/FN

    Yes No Yes No Yes No Yes No Yes No TAD

     Parent Activity

     Parent UIC

    SF 600 Sent To Worksite

     Primary Noise Source

    Secondary Noise Source OPCODE

     Operation

    Task

    Ambient Operator Ambient Operator Ambient Operator Ambient Operator Ambient Operator Exposure Origin

    Related Shop SOP Workload Light/Normal/Heavy Light/Normal/Heavy Light/Normal/Heavy Light/Normal/Heavy Light/Normal/Heavy PPE Description (if used)

    Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown PPE Adequate

    Field #

     Sample #

     Time Off

     Time On

     Sample Duration (min.)

    3dB 3dB 3dB 3dB 3dB Dose (%) 4dB 4dB 4dB 4dB 4dB

    3dB 3dB 3dB 3dB 3dB Lavg (dBA) 4dB 4dB 4dB 4dB 4dB

    4dB 4dB 4dB 4dB 4dB Lmax (dBA) 3dB 3dB 3dB 3dB 3dB

    3dB 3dB 3dB 3dB 3dB 8 Hour TWA (dBA) 4dB 4dB 4dB 4dB 4dB

    3dB 3dB 3dB 3dB 3dB Shift TWA (dBA) 4dB 4dB 4dB 4dB 4dB

    3dB 3dB 3dB 3dB 3dB 8 Hour Projected Dose

    TWA (%) 4dB 4dB 4dB 4dB 4dB NMCPHC 5100/18 (REV 11/2009) For Official Use Only Privacy Sensitive: Any misuse or unauthorized disclosure may result in both civil and criminal penalties.

    NOISE DOSIMETER 1 NOISE DOSIMETER 2

    Mfg: Serial # : Mfg: Serial # :

    Model: Name: Model: Name:

    Last Electroacoustic Cal Date: Next Electroacoustic Cal Date: Last Electroacoustic Cal Date: Next Electroacoustic Cal Date:

    NOISE DOSIMETER 3 NOISE DOSIMETER 4

    Mfg: Serial # : Mfg: Serial # :

    Model: Name: Model: Name:

    Last Electroacoustic Cal Date: Next Electroacoustic Cal Date: Last Electroacoustic Cal Date: Next Electroacoustic Cal Date:

    NOISE DOSIMETER 5 CALIBRATOR

    Mfg: Serial # : Mfg: Serial # :

    Model: Name: Model: Name:

    Last Electroacoustic Cal Date: Next Electroacoustic Cal Date: Last Electroacoustic Cal Date: Next Electroacoustic Cal Date:

    Field Calibration: Pre Cal Date: ____________________________________ Post Cal Date: __________________________________

    Field Calibration OK: ___ Yes ___ No Field Calibrated By: __________________________________

    Exposure during the unsampled period is: __ Same as sample period __ Zero __ Other ____________________________________

    Shift Length: ____________ Actual Length of Sampled Work: ____________________ Time Course of Events/Comments:

    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    _______________________________________________________________________________________________________

    Sampler: _______________________________________________________________________________ Date Completed: ____________

    Reviewing IH: ___________________________________________________________________________ Date Reviewed: ____________

    Data Entered By: ____________________________________________________________________________ Date Entered: ____________

    PRIVACY ACT STATEMENT: Authority: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 1095, Collection from Third Party Payers Act; 10 U.S.C. 5131 (as amended); 10 U.S.C. 5132; 44 U.S.C. 3101; 10 CFR part 20, Standards for Protection Against Radiation; 29 CFR, Labor Standards; and, E.O. 9397 (SSN). Purpose: This system is used by officials, employees and contractors of the Department of the Navy in the performance of their official duties relating to the health and medical treatment of Navy and Marine Corps members and civilian employees. Use: Information is close-hold and shared with only those with a need-to-know. Supervisory personnel will have access to information concerning their employees. Administrative/web personnel will have access for purposes of maintaining the data base. Disclosure of information is treated as “For Official Use Only Privacy Sensitive”. Disclosure: Disclosure of the requested information is voluntary; however, if not provided, acceptance of the submitted record may be denied.

NMCPHC 5100/18 (REV 11/2009) For Official Use Only Privacy Sensitive: Any misuse or unauthorized disclosure may result in both civil and criminal penalties.

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