Job Hazard Analysis (JHA) Process - Major Task Group
Hazard Identification for Each Work Step Using Energy Mapping
Project Name
*
911 Location
*
The address the ambulance needs to find you.
Date
*
-
Month
-
Day
Year
Date
Please use 24-hour time
Project Manager Name and Phone Number
*
Please Select
Angel Villareal - (708) 548-1344
Jordan Williams - (630) 306-0111
Kyle Charpie - (843) 367-7600
Chuck VonDrehle - (312) 806-2164
Dave Mason - (630) 999-3499
Sara Ignoffo - (312) 402-0261
Andris Gudins - (201) 647-6478
Nick Markewych - (708) 218-0945
Who do you call for changes on the job?
Safety Department Contact
*
Please Select
Karl DeLooff - (616) 530-0442
Dominic Sebilla - (816) 491-9536
Scope of Work (Major Task Group)
What are the major task groupings or steps in the work to be performed?
Time
Please use 24-hour time
Project Manager
First Name
Last Name
Project Manager Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Project Manager Email
example@example.com
Safety Department Contact
*
First Name
Last Name
Safety Department Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Weather Forecast Review (Temperature / Wind Speed / Wind Direction / Precipitation / Storm Potential)
Current Day (0-24 Hours)
Next 25-48 Hours
Next 49-72 Hours
Next 73-96 Hours
Scope of Work Steps / WBS (How the Job Will Actually Be Done)
These are the main steps or work assignments that the crew needs to be organized and prepare to execute.
Hazard Identification for Each Work Step Using Energy Mapping
Electrical / Gravity / Kinetic / Mechanical / Chemical / Thermal / Pressure / Environmental
What energy will the people be exposed to during the work?
Hazard Controls by Hierarchy (Eliminate / Substitute / Engineer / Admin / PPE)
What is necessary to reduce the potential energy exposure to safer levels? "Be careful" is not acceptable.
Site Lead
First Name
Last Name
Forklift Operator
First Name
Last Name
Material Handling Spotter
First Name
Last Name
Daily Safety Inspector
First Name
Last Name
Other Roles, Responsibilities & Decision Authority by Name
Who is doing what? Get specific so people know what crew they are working on and who has what role within the crew.
Training & Competencies (QEW, Signalperson, Forklift Operator, spotter, etc.) by name
Does any of the tasks require specific competency, qualification, or training? If so, list them out and make sure there is a qualified person to accomplish that task. If not, do not perform that task until there is a competent or qualified person. Contact the Project Manager and detail the requirements.
Equipment & Tools Required / Inspection Requirements / Instrumentation/Serial Number
What tools or equipment do you need to accomplish the task? If calibration or certification is required, list it here. If you don't have what you need contact the Project Manager.
Communications Requirements (Radio / Cell Phone / Signals)
Emergency Provisions (Rescue Equipment / First Aid / Eyewash / Site Access / Occupational Clinic)
What is the address for the local occupational medical clinic? Do you have the first aid materials you need for the potential work? If you need to LOTO, do you have the proper equipment to rescue someone from electrical contact?
Hold Points & Verification Checks (Test for No Voltage / Anchor Verification / Lift Plan Checks) QAQC req
If there are additional permits, list them here. If there are inspections required, list them here.
Traffic Plan / Deliveries / Visitors / Local Conditions
How to you ensure that deliveries can be offloaded on time? Do you have space for the deliveries? Are visitors expected? Anything that needs to be known but not covered in the previous entires?
End-of-Day Foreman Certifications
The work today has been performed
Without injury
An injury has occurred
Comments
The work performed today
Complies with QAQC requirements
Rework was required
Rework will be required
Comments
All materials subject to becoming wind driven have been properly secured.
Yes
No
Comments
Foreman Name
First Name
Last Name
Foreman Signature
Date
-
Month
-
Day
Year
Date
Signatures
By signing below, I agree I have received a briefing on the tasks and hazards found on this job site. I agree to report any uncontrolled or undisclosed hazards as I become aware of them.
Worker 1
First Name
Last Name
Worker 1 Signature
Worker 2
First Name
Last Name
Worker 2 Signature
Worker 3
First Name
Last Name
Worker 3 Signature
Worker 4
First Name
Last Name
Worker 4 Signature
Worker 5
First Name
Last Name
Worker 5 Signature
Worker 6
First Name
Last Name
Worker 6 Signature
Worker 7
First Name
Last Name
Worker 7 Signature
Worker 8
First Name
Last Name
Worker 8 Signature
Worker 9
First Name
Last Name
Worker 9 Signature
Worker 10
First Name
Last Name
Worker 10 Signature
Worker 11
First Name
Last Name
Worker 11 Signature
Worker 12
First Name
Last Name
Worker 12 Signature
Worker 13
First Name
Last Name
Worker 13 Signature
Worker 14
First Name
Last Name
Worker 14 Signature
Worker 15
First Name
Last Name
Worker 15 Signature
Worker 16
First Name
Last Name
Worker 16 Signature
Worker 17
First Name
Last Name
Worker 17 Signature
Worker 18
First Name
Last Name
Worker 18 Signature
Worker 19
First Name
Last Name
Worker 19 Signature
Worker 20
First Name
Last Name
Worker 20 Signature
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