Form Approved
OMB No. 0920-0109
Exp. Date xx/xx/20xx
Determination of Noise Level Test Data Sheet
Task Number: ____________________________________ Date: _______________________________
Manufacturer: ____________________________________
Item Tested: ________________________________________________________________________________________________________
Room dba: _____________ Trial #1 Trial #2
NIOSH # |
Subject |
Left Ear |
Right Ear |
Left Ear |
Right Ear |
Max dba |
PASS/FAIL |
|
Manikin
|
|
|
|
|
85 |
|
|
#1
|
|
|
|
|
80 |
|
|
#2 |
|
|
|
|
80 |
|
|
#3 |
|
|
|
|
80 |
|
Comments: __________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
ETB-1014-APR-0030 Rev 3
Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSD Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0109).
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | NIOSH |
| File Modified | 0000-00-00 |
| File Created | 2023-12-12 |