Workplace Noise Risk Assessment Form

Assessment Details

Date of Assessment Assessor Name Department/Location

Noise Source(s)

Source/Equipment	Area/Location	Duration of Exposure	Noise Level (dB)

Exposed Employees

List of Employees Exposed to Noise

Current Controls

Existing Control Measures

Risk Assessment

Risk Level (Low/Medium/High) Low Medium High Details/Comments

Additional Actions Required

Recommended Actions Person Responsible Target Date

Review

Review Date Reviewer