Job Hazard Analysis (JHA) Process - Major Task Group
Hazard Identification for Each Work Step Using Energy Mapping
Project Name
911 Location
Date
-
Month
-
Day
Year
Date
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.
Scope of Work (Major Task Group)
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)
Hazard Identification for Each Work Step Using Energy Mapping
Electrical / Gravity / Kinetic / Mechanical / Chemical / Thermal / Pressure / Environmental
Hazard Controls by Hierarchy (Eliminate / Substitute / Engineer / Admin / PPE)
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
Training & Competencies (QEW, Signalperson, Forklift Operator, spotter, etc.) by name
Equipment & Tools Required / Inspection Requirements / Instrumentation/Serial Number
Communications Requirements (Radio / Cell Phone / Signals)
Emergency Provisions (Rescue Equipment / First Aid / Eyewash / Site Access / Occupational Clinic)
Hold Points & Verification Checks (Test for No Voltage / Anchor Verification / Lift Plan Checks) QAQC req
Traffic Plan / Deliveries / Visitors / Local Conditions
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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