Noise-Induced Hearing Loss Incident Form
Date of Incident
Time of Incident
Employee Name
Employee ID
Department/Location
Describe the Incident
Specific Source of Noise
Estimated Noise Level (dB)
Duration of Exposure
Was Hearing Protection Used?
Yes
No
Type of Hearing Protection
Symptoms Noticed
Actions Taken After Incident
Reported To (Supervisor/Department)
Additional Comments