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Hearing conservation program template

A working record of a US hearing conservation program under OSHA 1910.95, filled in on a phone. Add each noisy area or job with its measured 8-hour TWA, and the form shows whether it is at or above the 85 dBA action level or above 90 dBA. Enter the protector's NRR for an Appendix B estimate of the level under it. List each employee in the program with the baseline and most recent audiogram dates: the form counts the days since and flags anyone over a year. Record standard threshold shift follow-up, the protectors offered and each training session.

For EHS coordinators, plant managers and safety consultants running a hearing conservation program in a factory, warehouse or workshop, who need one record they can update after each noise survey and audiogram round.

Written for US OSHA rules. In Great Britain, use the noise risk assessment and the noise monitoring report under the Control of Noise at Work Regulations 2005.

  • Areas and jobs with the measured 8-hour TWA against 85 and 90 dBA
  • Appendix B estimate of the level under the hearing protector, from its NRR
  • Employees with baseline and latest audiogram dates, days since and an overdue flag
  • Standard threshold shift follow-up, with the 21-day written notice checked
  • Protectors offered, training sessions, records, actions and two signatures
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What does a hearing conservation program need?

A hearing conservation program record is useful when every employee at or above 85 dBA has dated audiograms you can see at a glance, and the noise results, protector choice and training line up with the areas they work in. The days-since counts are what catch the person who missed the van.

Last updated . Facts checked by the SiteSurvey team on 27 October 2026 against OSHA 29 CFR 1910.95, occupational noise exposure (eCFR) and HSE: The Control of Noise at Work Regulations 2005.

How to run a hearing conservation program record

Start it after your noise survey and update it after each audiogram round and training session.

  1. Set up the program

    Enter the employer, the person running the program, the audiometric testing provider and who performs the tests, and whether mobile test vans are used.

  2. Add each noisy area

    For each area or job, record how and when noise was measured, the instrument and the 8-hour TWA. The form shows the result against 85 and 90 dBA. Record that employees were told the results.

  3. Check the protectors

    Enter the NRR of the protector used in each area and the Appendix B method. The form estimates the level under the protector and flags anything above 90 dBA.

  4. List the employees

    For each employee at or above 85 dBA, enter the first exposure date, baseline and most recent audiogram. The form counts the days since and flags any over a year.

  5. Follow up any STS

    Where an audiogram shows a standard threshold shift, record when it was found, when the employee was told in writing and the follow-up steps taken.

  6. Log training and sign

    Add each training session and the topics covered, confirm the standard is posted and where records are kept, then add actions and sign.

What makes a hearing conservation program record useful

Each employee: first exposure, baseline, most recent audiogram, days since, STS follow-up

Metal stamping plant, Toledo, 14 October: press line 1 measured at 92.4 dBA TWA by dosimetry; foam plugs with NRR 29 give an Appendix B estimate of 70.4 dBA. Press operator D. Okafor's last audiogram was 19 August 2025, 421 days ago: missed the August van visit. Clinic audiogram booked for 21 October.

Fictional example. Record the actual evidence and approved arrangements for your job.

A common recording mistake

Testing whoever turns up on van day and never checking who was missed, so one operator goes two years without an audiogram.

What happens next

Before each van visit or training round, open the record, sort out anyone flagged over a year, and re-measure any area where presses, tools or controls have changed.

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Every question in the hearing conservation program template

A US hearing conservation program record under OSHA 29 CFR 1910.95: noise monitoring by area and job against the 85 dBA action level and the 90 dBA Table G-16 limit, results given to employees, hearing protectors with an Appendix B estimate of the level under them, each employee in the program with baseline and most recent audiogram dates and days since, standard threshold shift follow-up, protectors offered, training sessions, records and actions. 6 sections and 127 questions. Follow-up questions and guidance appear only when an answer calls for them, so the person on site never sees the ones that do not apply.

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  • Project: the project name
  • Site address: the site address, from the space or the project
  • Site or owner: the project's customer

Program, employer and audiometric provider

  • ProjectShort answer

    Filled in from the project in SiteSurvey.

    Fills in from the project name
  • Site addressShort answer
    Fills in from the site address, from the space or the project
  • Site or ownerShort answer
    Fills in from the project's customer
  • Location (GPS)Short answer
  • Program review date*Date
  • Reviewed by*Short answer
  • Employer*Short answer
  • Person running the program*Short answer
  • Audiometric testing providerShort answer

    Clinic, mobile test van company or in-house tester.

  • Tests performed byChoose one

    1910.95(g)(3).

    • Licensed or certified audiologist
    • Otolaryngologist or other physician
    • Technician (CAOHC certified or shown competent), responsible to an audiologist, otolaryngologist or physician
  • Are mobile test vans used for audiograms?Yes or No
  • Audiometric testing and hearing protectors provided at no cost to employees?*Yes or No

    1910.95(g)(2), (i)(1).

  • Next program review dueDate

    Your own review date: 1910.95 sets yearly audiograms and training, not a program review date.

  • GuidanceWhen a hearing conservation program is needed (29 CFR 1910.95(c)). Whenever employee noise exposure equals or exceeds an 8-hour time-weighted average (TWA) of 85 dBA, or a dose of 50 percent: the action level. Exposure is worked out without counting any hearing protector. The program covers monitoring, employee notification, audiometric testing, hearing protectors, attenuation, training, access to information and records (1910.95(c) to (m)). Separately, where sound exceeds Table G-16 (90 dBA for 8 hours), feasible engineering or administrative controls are used first, and hearing protectors where they do not bring levels within the table (1910.95(b)(1)).
  • GuidanceParagraphs (c) to (n) do not apply to employers engaged in oil and gas well drilling and servicing operations (1910.95(o)).
  • GuidanceWorking in Great Britain? This form follows US OSHA rules. Use the noise risk assessment and noise monitoring record under the Control of Noise at Work Regulations 2005 instead.

Noise monitoring by area and job

  • GuidanceMonitor when information shows any employee may be exposed at or above 85 dBA TWA, to find who belongs in the program and to choose hearing protectors. Repeat it when a change in production, process, equipment or controls increases exposure so that more employees may reach the action level, or the protectors in use may no longer be enough (1910.95(d)).
  • Areas and jobs
    Repeat for each entry. Each one asks:
    • Area or job*Short answer

      For example: Press line 1, Weld cell, Shipping dock.

    • Jobs and tasks hereShort answer
    • Main noise sourcesNotes

      For example: 200-ton presses, air blow-off, part chutes.

    • Employees who work hereNumber
    • How it was measured*Choose one

      Use personal sampling where workers move about, levels vary a lot or there is a lot of impulse noise, unless area sampling gives the same results (1910.95(d)(1)(ii)).

      • Personal dosimetry
      • Area monitoring with a sound level meter
      • Both
    • Measured onDate
    • Measured byShort answer
    • InstrumentShort answer
    • Instrument calibrated for this measurement?*Yes or No

      1910.95(d)(2)(ii).

    • Measured 8-hour TWA (dBA)*Number

      Without counting any hearing protector (1910.95(c)(1)). Integrate all sound from 80 to 130 dB (1910.95(d)(2)(i)).

    • Result against the limitsWorked out by the form
      Shown when “Measured 8-hour TWA (dBA)” is answered
    • Highest impulse or impact peak (dB), if measuredNumber
    • CheckExposure to impulsive or impact noise should not exceed 140 dB peak sound pressure level (1910.95, Table G-16 footnote).
      Shown only when the answers above make it relevant
    • Employees at or above 85 dBA told the results?*Yes or No

      1910.95(e).

      Shown only when the answers above make it relevant
    • Employees or their representatives offered the chance to watch the measurements?Yes or No

      1910.95(f).

    • Engineering or administrative controls in place or planned*Notes

      For example: press enclosure, quieter air nozzles, job rotation.

      Shown only when the answers above make it relevant
    • WarningAbove the Table G-16 limit: use feasible engineering or administrative controls; if they do not bring levels within the table, provide hearing protectors and make sure they are worn (1910.95(b)(1), (i)(2)(i)).
      Shown only when the answers above make it relevant
    • Hearing protectors required in this area?Yes or No
      Shown only when the answers above make it relevant
    • NRR of the hearing protector used hereNumber

      From the protector package.

      Shown only when the answers above make it relevant
    • Appendix B method used for the estimateChoose one
      • A-weighted TWA or level (subtract the NRR minus 7)
      • C-weighted level (subtract the NRR)
      Shown only when the answers above make it relevant
    • C-weighted level (dBC)*Number
      Shown when “Appendix B method used for the estimate” is “C-weighted level (subtract the NRR)”
    • Estimated TWA under the protector (dBA)Worked out by the form
      Shown only when the answers above make it relevant
    • Protector adequacyWorked out by the form
      Shown only when the answers above make it relevant
    • GuidanceProtectors must bring exposure to at least 90 dBA TWA, and to 85 dBA or below for employees with a standard threshold shift (1910.95(j)(2), (3)). Appendix B: calculated values are realistic only to the extent the protectors are properly fitted and worn.
      Shown only when the answers above make it relevant
    • Photos of the area and noise sourcesPhotos
    • a_inWorked out by the form
    • a_overWorked out by the form
    • a_not_toldWorked out by the form
    • a_not_calWorked out by the form
    • a_weakWorked out by the form
    • a_peak_flagWorked out by the form
  • Areas measuredWorked out by the form
  • At or above 85 dBAWorked out by the form
  • Above 90 dBAWorked out by the form
  • Results not yet given to employeesWorked out by the form
  • Protector estimate above 90 dBAWorked out by the form
  • Measurements without a calibrated instrumentWorked out by the form
  • Peaks above 140 dBWorked out by the form

Employees in the program and audiometric testing

  • GuidanceAudiometric testing is made available to every employee at or above 85 dBA TWA: a baseline within 6 months of first exposure at or above the action level (within 1 year where mobile test vans are used), then at least once a year, each compared with the baseline (1910.95(g)).
  • Employees in the hearing conservation program
    Repeat for each entry. Each one asks:
    • Employee (name or ID)*Short answer
    • Job classificationShort answer
    • Area or job groupShort answer
    • Most recent exposure assessment (8-hour TWA, dBA)Number
    • First exposure at or above 85 dBADate
    • Baseline audiogramDate
    • Days from first exposure to baselineWorked out by the form
      Shown when “First exposure at or above 85 dBA” is answered and “Baseline audiogram” is answered
    • Baseline within 6 months of first exposure (1 year with a mobile test van)?*Choose one

      1910.95(g)(5)(i), (ii).

      • Yes
      • No
      • Not done yet
    • Days since first exposureWorked out by the form
      Shown when “Baseline within 6 months of first exposure (1 year with a mobile test van)?” is “Not done yet” and “First exposure at or above 85 dBA” is answered
    • CheckUntil the baseline is done: where it comes more than 6 months after first exposure (mobile test van), the employee wears hearing protectors from 6 months after first exposure until the baseline is obtained (1910.95(g)(5)(ii), (i)(2)(ii)(A)). Baseline testing follows at least 14 hours without workplace noise; hearing protectors may stand in for this (1910.95(g)(5)(iii)).
      Shown only when the answers above make it relevant
    • Most recent audiogram*Date

      The baseline date if there has been no annual audiogram yet.

      Shown only when the answers above make it relevant
    • Days since the most recent audiogramWorked out by the form
      Shown when “Most recent audiogram” is answered and “Program review date” is answered
    • Annual audiogramWorked out by the form
      Shown when “Most recent audiogram” is answered and “Program review date” is answered
    • WarningMore than a year since the last audiogram. A new audiogram is obtained at least annually after the baseline for each employee at or above 85 dBA TWA (1910.95(g)(6)).
      Shown only when the answers above make it relevant
    • ExaminerShort answer
    • Most recent audiogram compared with the baseline*Choose one
      • No standard threshold shift
      • Standard threshold shift (STS)
      • Possible STS: retest within 30 days pending
      • Baseline only so far
      Shown only when the answers above make it relevant
    • GuidanceA standard threshold shift is an average change of 10 dB or more at 2000, 3000 and 4000 Hz in either ear compared with the baseline; age correction under Appendix F is allowed (1910.95(g)(10)). The employer may retest within 30 days and use the retest as the annual audiogram (1910.95(g)(7)(ii)).
      Shown only when the answers above make it relevant
    • STS determined on*Date
      Shown when “Most recent audiogram compared with the baseline” is “Standard threshold shift (STS)”
    • Employee told in writing onDate
      Shown when “Most recent audiogram compared with the baseline” is “Standard threshold shift (STS)”
    • Days to tell the employeeWorked out by the form
      Shown when “Most recent audiogram compared with the baseline” is “Standard threshold shift (STS)” and “STS determined on” is answered and “Employee told in writing on” is answered
    • WarningThe employee is told of an STS in writing within 21 days of the determination (1910.95(g)(8)(i)).
      Shown only when the answers above make it relevant
    • Follow-up after the STSTick all that apply

      1910.95(g)(8)(ii).

      • Fitted with hearing protectors, trained and required to use them
      • Refitted and retrained, with protectors of greater attenuation if necessary
      • Referred for a clinical audiological evaluation or otological examination
      • Told of the need for an otological examination
      • Physician determined the STS is not work related or aggravated by occupational noise
      Shown when “Most recent audiogram compared with the baseline” is “Standard threshold shift (STS)”
    • STS follow-up complete?*Yes or No
      Shown when “Most recent audiogram compared with the baseline” is “Standard threshold shift (STS)”
    • Hearing protector wornShort answer
    • Last hearing conservation trainingDate
    • Days since trainingWorked out by the form
      Shown when “Last hearing conservation training” is answered and “Program review date” is answered
    • CheckTraining is repeated each year for each employee in the program (1910.95(k)(2)).
      Shown only when the answers above make it relevant
    • NotesNotes

      No medical details beyond what the program needs.

    • e_overdueWorked out by the form
    • e_base_lateWorked out by the form
    • e_stsWorked out by the form
    • e_sts_lateWorked out by the form
    • e_sts_openWorked out by the form
    • e_train_dueWorked out by the form
  • Employees in the programWorked out by the form
  • Annual audiogram overdueWorked out by the form
  • Baseline lateWorked out by the form
  • Standard threshold shiftsWorked out by the form
  • STS not told in writing within 21 daysWorked out by the form
  • STS follow-up not completeWorked out by the form
  • Training more than a year ago or not recordedWorked out by the form

Hearing protectors and attenuation

  • GuidanceHearing protectors are available at no cost to every employee at or above 85 dBA TWA and replaced as necessary. Employees choose from a variety of suitable protectors, get training in use and care, and are fitted at the start, with correct use supervised (1910.95(i)). They are worn by anyone required to wear PPE under 1910.95(b)(1), and by employees at or above 85 dBA who have had a standard threshold shift or are waiting for a baseline under the mobile van rule (1910.95(i)(2)).
  • Hearing protectors offered
    Repeat for each entry. Each one asks:
    • Type*Choose one
      • Foam earplugs
      • Pre-molded earplugs
      • Banded earplugs
      • Custom-molded earplugs
      • Earmuffs
      • Cap-mounted earmuffs
      • Other
    • Make and modelShort answer
    • NRR on the packageNumber
    • Sizes availableShort answer
    • Where employees get themShort answer
  • Types offeredWorked out by the form
  • Can employees choose from a variety of suitable protectors?*Yes or No

    1910.95(i)(3).

  • Initial fitting done and correct use supervised?*Yes or No

    1910.95(i)(5).

  • Protectors replaced as necessary?*Yes or No
  • Attenuation evaluation method (Appendix B)*Choose one

    Attenuation is evaluated for the specific noise environments where each protector is used (1910.95(j)(1)).

    • NRR method
    • NIOSH method #1B1
    • NIOSH method #1B2
    • NIOSH method #1B3
  • Attenuation re-evaluated after any increase in exposure?Yes or No

    1910.95(j)(4). Answer Yes if there has been no increase.

  • Photos of the protector stationsPhotos
  • hp_flagsWorked out by the form

Training, information and records

  • GuidanceEach employee at or above 85 dBA TWA is trained, and the training is repeated every year and kept up to date with changes in protective equipment and work processes (1910.95(k)).
  • Training sessions
    Repeat for each entry. Each one asks:
    • Session*Short answer

      For example: Annual hearing conservation refresher, first shift.

    • Held on*Date
    • Given byShort answer
    • Covered*Tick all that apply

      1910.95(k)(3).

      • Effects of noise on hearing
      • Hearing protectors: purpose, types, attenuation, selection, fitting, use and care
      • Purpose of audiometric testing and how the test is done
    • Employees attendingNumber
    • Who attendedNotes
    • s_gapsWorked out by the form
  • Sessions recordedWorked out by the form
  • Required topics missed in sessionsWorked out by the form
  • Copy of 1910.95 posted in the workplace and available to affected employees?*Yes or No

    1910.95(l)(1).

  • Last acoustic or exhaustive calibration of the audiometer (from the provider)Short answer

    Kept with the audiometric test records (1910.95(m)(2)(ii)(D)).

  • Provider keeps records of background sound levels in the test room?Yes or No

    1910.95(m)(2)(ii)(F).

  • Where the exposure and audiometric records are keptShort answer
  • GuidanceExposure measurement records are kept for two years and audiometric test records for the duration of the employee's employment. All are provided on request to employees, former employees, their designated representatives and OSHA (1910.95(m)(3), (4)).
  • std_flagWorked out by the form

Result, actions and sign-off

  • Items needing actionWorked out by the form
  • ResultWorked out by the form
  • Actions
    Repeat for each action. Each one asks:
    • Action*Notes
    • PriorityChoose one
      • Now
      • Within 30 days
      • Before the next audiogram round
      • Before the next review
    • Who will do it*Short answer
    • Due byDate
    • Status*Choose one
      • Open
      • In progress
      • Done, checked
    • Photo when donePhotos
      Shown when “Status” is “Done, checked”
  • Actions still openWorked out by the form
  • Decision*Choose one
    • Program in place and up to date
    • In place: actions to finish
    • Gaps that need action now
  • Next check or re-inspection dateDate
  • Summary for the clientNotes
  • Program lead nameShort answer
  • Program lead signature*Signature
  • Employer representative nameShort answer
  • Employer representative signatureSignature

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A completed hearing conservation program report, made by SiteSurvey from a fictional site visit: every answer, the photos, the guidance that applied and the sign-off, ready to send as a PDF.

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Hearing conservation program FAQs

When is a hearing conservation program required?

When employee noise exposure equals or exceeds an 8-hour time-weighted average of 85 dBA, or a dose of 50 percent, measured without counting any hearing protector. Separately, where sound exceeds Table G-16 (90 dBA for 8 hours), the employer uses feasible engineering or administrative controls, and hearing protectors where those do not bring levels within the table (1910.95(b), (c)). Paragraphs (c) to (n) do not apply to oil and gas well drilling and servicing.

Source: OSHA 29 CFR 1910.95, occupational noise exposure (eCFR).

How often are audiograms needed?

A valid baseline audiogram within 6 months of an employee's first exposure at or above the action level, or within 1 year where mobile test vans are used, then a new audiogram at least once a year, each compared with the baseline (1910.95(g)(5), (6), (7)). The form works out the days since each employee's most recent audiogram and flags anyone over a year.

Source: OSHA 29 CFR 1910.95, occupational noise exposure (eCFR).

What is a standard threshold shift and what follows one?

A change in hearing threshold, relative to the baseline, averaging 10 dB or more at 2000, 3000 and 4000 Hz in either ear. The employee is told in writing within 21 days. Unless a physician finds it is not work related, the employee is fitted or refitted with hearing protectors and trained, given protectors with more attenuation if needed, and referred for further evaluation where appropriate (1910.95(g)(8), (10)).

Source: OSHA 29 CFR 1910.95, occupational noise exposure (eCFR).

How does the form estimate protection from a hearing protector?

It uses the NRR method in Appendix B of 1910.95. With an A-weighted TWA, it subtracts 7 from the NRR and subtracts the rest from the TWA; with a C-weighted level, it subtracts the NRR. Protectors must bring exposure to 90 dBA or below, and to 85 dBA or below for anyone with a standard threshold shift. Appendix B notes the result is only as good as the fit and wear of the protector.

Source: OSHA 29 CFR 1910.95, occupational noise exposure (eCFR).

Does the form send audiogram reminders?

No. SiteSurvey does not schedule tests or send reminders. The form shows the days since each audiogram and training date and flags those over a year when you open the record, so check it before each van visit or training round. It records the program; it does not make you compliant or interpret audiograms.

Can I use this on a UK site?

No. It follows US OSHA rules. In Great Britain the Control of Noise at Work Regulations 2005 apply: HSE says employers assess the risk and give information and training at 80 dB(A), provide hearing protection and hearing protection zones at 85 dB(A), and provide health surveillance for workers regularly exposed above 85 dB(A). Use the noise risk assessment instead.

Source: HSE: The Control of Noise at Work Regulations 2005.

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