Job Hazard Analysis
Date
*
-
Month
-
Day
Year
Date
Author/Planner
*
First Name
Last Name
Email
example@example.com
Project Number
*
Project Name
*
Department
*
Select One
Roofing
Rover
Waterproofing
Wall Panels
Glazing
Service
Perimeter Flashing
Crew Size
Start Time
End Time
Location of Work
Task to be Accomplished
*
Housekeeping Plan (Trash removal, Clean-up, Responsible person, Frequency)
Material Storage & Handling Plan (Deliveries, Laydown, Equipment)
Access and Hoisting Plan (Personnel & Materials)
Consider the work to be performed and check either 'Yes' or 'No'.
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Yes
No
Does every crew member know how to use assigned tools & equipment?
Does this work require special training?
Do you need additional or special personnel to complete this task?
Do you need additional or special materials and tools to do the job?
Do you need to review an SDS prior to proceeding with this work?
Will weather conditions affect the safety or quality of this work?
Is there adequate lighting and access?
Does this task require shutdown of systems and/or equipment?
Is there any potential to impact existing Owner or Construction activity?
Have shop drawings, contract drawings or as-builts been reviewed?
Does work involve awkward positions, heavy and/or repetitive lifting?
Crew knows location of fire extinguishers, eye washes, phones?
Does this task require any special permits/procedures?
Are employees assigned a “mentor”?
Do other Subs need to be involved?
Are there occupied spaces adjacent or below?
Provide any additional information as needed:
Check any/all of the following that apply
*
Public Interface
Traffic Control
Barricades/Signs
Confined Space
Asbestos Abatement
Chemical Exposure
Ventilation
Electrical Hazards
Lock-Out/Tag-Out
Open Flame
Critical Life Plan
SDS
Equipment
Crane
Lull/Lift
Forklift
Aerial Boom
Scissor Lift
Other
PPE Requirements
*
Fall Protection PPE
Hand/Arm PPE
Full Body PPE
Respirator PPE
Hearing PPE
Eye/Face PPE
Other
Identify Potential Hazards
*
IF WORK CONDITIONS CHANGE, WORK MUST STOP AND A NEW PLAN MUST BE PREPARED
Operator Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
General For All Equipment
Yes
No
Hydraulic Hoses & Cylinder
Fuel Tank: Secure
Engine Checks: Filters, Belts, Fan Blades
Electrical Components, Wiring and Cables, Lights, Alarms/Beeper
Yes
No
Tires, Wheels, Bolts: Checked for Damage, Loose Bolts, Tire Pressure
Capacity Plate Load Chart: Readable & Understood
Fluid Checks: Transmission, Coolant, Battery, Brakes
Operator's Manual & Warning Decals: Visible, Readable
Lull
Merit Equipment
Rental Equipment
Other
Lull Checklist
Yes
No
Forks, Carriage: Free of Damaged, Bent Worn
Overhead Guard/Cage: Good Working Condition
Brakes, Pedals, Controls
Yes
No
Mast/Boom Arm: Loose/Missing Parts, Excessive Wear or Leaks
Seat & Seatbelt: Good Working Condition Brakes, Pedals, Controls
Additional Notes on Lull
Aerial Boom
Merit Equipment
Rental Equipment
Other
Aerial Boom Checklist
Yes
No
Hydraulic Power unit, reservoir hoses, fittings, manifolds
Boom wear pads, gauges, lights
Fall Protection Devices: Rails, Gates, Anchors, etc.
Yes
No
Drive and Turntable motors and torque hubs
Control operations - test of base and basket
Additional Notes on Aerial Boom
Scissor Lift
Merit Equipment
Rental Equipment
Other
Scissor Lift Checklist
Yes
No
Fall Protection Devices: Rails, Gates, Anchors, etc.
Extension Arms: free from damage
Yes
No
Control operations - test of base and platform
Outriggers (if present on lift)
Additional Notes on Scissor Lift
Forklift
Merit Equipment
Rental Equipment
Other
Forklift Checklist
Yes
No
Forks, Carriage, Mast, Mast Guard
Seat & Seatbelt: Good Working Condition
Yes
No
Propane, Valves, Safety Straps
Brakes, Pedals, Controls
Additional Notes on Forklift
The tasks have been reviewed in the work area where they will be performed and this plan has been reviewed with the workers on this crew.
Foreman Signature
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