Employer site supplement: hearing conservation
Use with the employer’s responsible person and actual workplace information.
Complete with the employer's responsible person using actual site information. This practical discussion record is not an OSHA certificate, a compliance determination, or a substitute for required employer records. Completing the generic course does not replace monitoring, actual protector fitting, audiometric testing, or site-specific instruction. Leave unknown items marked unresolved and assign follow-up. Do not place medical test results on this general training form.
| Item | Employer-provided information |
|---|---|
| Employer / site | |
| Employee / job or assignment | |
| Date discussed / responsible person's name or role | |
| Exposure assessment date and record location | |
| Measurement applies to these tasks, areas and durations | |
| Individual sampling or representative assessment; applicability explained | |
| Eight-hour time-weighted average in dBA or noise dose in percent; identify which | |
| Changes since the assessment needing review | |
| Tasks / areas where hearing protection is required | |
| When protection must be put on and may be removed | |
| Suitable protector options supplied | |
| Selected model / size / required combination, if any | |
| Actual fitting instruction date / instructor / checklist location | |
| Supply and replacement location; access on this shift | |
| Care instructions location / replacement procedure | |
| Audiometric scheduling contact / contact method | |
| Test location / appointment arrangement / instructions source | |
| Baseline status confirmed with program contact; follow-up needed | |
| Noise-monitoring questions contact / method | |
| Protector-use or supply concerns contact / method | |
| Hearing concerns / testing questions contact / method | |
| Exposure and audiometric record-request process | |
| Where standard and training information are available |
Unresolved items
| Missing information or action | Responsible person | Target date | Resolution / date |
|---|---|---|---|
Employer discussion checks
Mark each item only after actually reviewing it; these checkboxes do not establish compliance.
- Applicable exposure result and its meaning explained.
- Required wear instructions identified for this assignment.
- Suitable supplied protectors identified and selected.
- Actual-model fitting and correct use practiced; unresolved issues recorded.
- Supply, care, and replacement procedures located.
- Hearing-test arrangements and instructions identified.
- Reporting contacts and record-access process identified.
- Changes or missing details assigned for follow-up.
Source basis: 29 CFR 1910.95(d)-(g), (i)-(m). The form's layout and tracking fields are practical aids, not federally prescribed form requirements. Federal general industry baseline. The employer must determine applicability and complete the site-specific review.