Date
-
Month
-
Day
Year
Date
Your Name
First Name
Last Name
Your Email Address
You will receive an editable copy of this JHA upon submission
Company Name
Project Site
Detected Location
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JHA Form
If you fill out your own JHA form please take a picture using the above widget and then scroll to bottom of this page and click 'Submit'. If you do not have an in-house JHA form please continue using this form.
Foreman
First Name
Last Name
Contact Phone Number
-
Area Code
Phone Number
Muster Area
Permit/s to be Performed
None
Hot Work
Excavation
Lock Out/ Tag Out
ROW Clearance
Critical Lift
Confined Space
Other
Job to be Performed
Do you have a COVID-19 Plan on your jobsite?
Yes
No (If "No" why?)
Have you reviewed the COVID-19 Plan with your crew?
Yes
No (If "No" why?)
If no why?
Tasks Associated With Job
Job Hazards & Controls
Check all that apply and give details as needed in the Tasks, Hazards and Controls section of this form
The Following Hazards and Controls were Identified and Discussed
Stop Work
The obligation of every person to stop work if something is not right
Other
Work Area Hazards
Confined space concerns
Moving equipment or vehicles
Lighting levels too high/ low
Extreme heat or cold
H2S
Severe weather
Excessive winds (high profile structures, flying dust & debris)
Uneven, wet, slippery, or muddy ground (unstable footing)
Ignition sources, static, grounding (Hotwork)
overhead utilities (clearance restrictions)
Working under energized lines requires access permission (Clearance)
Other
If working in Confined Space, Who Granted Access Permission
First & Last Name
Housekeeping
Job location clean and free of hazards
Clutter on job site
Garbage on ground
Signage present as necessary
Are tools and equipment clean and orderly
Other
Task Hazards
Ergonomic concerns (bending, lifting, etc.)
Potential for slips, trips and falls
Caught between hazards
Hand tool inspection
Fire hazards
Others working overhead or below
Other jobs in area (SIMOPS)
Other
Personal Protective Equipment (PPE)
Hardhat, safety glasses, safety-toed boots, high visibility clothing/ vest
Face shield, goggles or spoggels
Hearing protection
Gloves
Respiratory protection
Eyewash station- location identified
Proper attire for the job (welding, snakes, etc)
Other
Emergency & Communication
Job Paramedic is GEMS (EMT) tel:+5056972161
Communication resources available to call emergency responders
Emergency Action Plan present
Other
Electrical Safety
Grounding and bonding
GFCI for electric power tools
Safe distance of energized lines and equipment
Clearance requirements
Other
Confined Space Safety
All entrants have the required Confined Space Training
Confined Space is ventilated and adequate atmospheric testing is being conducted with an approved air quality monitor
Confined Space written work permit is filled out
All sources containing a hazardous substance leading to the confined space are safely and completely blocked off or disconnected
Competent watch person is present with effective emergency response plan
Other
Personnel Concerns
New employees/ inexperienced workers
Workers fit for duty (medications, sleep, physical limitations, distractions, etc.)
Workers clean and sharp with buttoned and zipped outer attire
Language barriers addressed
Other
Heavy Equipment or Cranes
Permit required
Current operator certification on file
Equipment daily inspections completed
Equipment swing radius clear
Positioning and outrigger location addressed
Overhead power lines, utilities, etc.
Air horn or other communication
Signal man or spotter
Pinch locations
Soft, hard, muddy, wet, sloped ground
Area cordoned off
Other
Driving Motorized Equipment
Seat belts used at all times
Condition of road or route
Spotter/ safety watch required
Unattended operation
Vehicle inspection
All loads secured
Other
Working at Heights
Man lift inspected
Fall protection plan reviewed
Proper tie-off points identified
Full body harness and lanyard/ lifeline
Fall protection equipment inspected
Ladder safety addressed
Overhead walking and working surfaces restricted, narrow, wet, slippery or icy
Scaffolding weight capacity identified
scaffolding shift inspection complete
Area cordoned off below work
Rescue personnel & procedure in place
Other
Hot Work
Fire extinguisher/ equipment at job location
Fire watch
Flammables, Combustibles or LEL in the area
Fire blanket
Ground rod for welding machine
Ground lead as close to weld as possible
Proper work attire
Other
Excavations and Trenching
Utility locate performed
Lines located, marked and drawings reviewed
Confined space concerns
Approved shoring in use
Proper sloping
Proper barricading around open holes
Proper egress provided
Competent person review
Permit requirements
Other
Energy Isolation
LOTO Training verified
Walk through and discussion of LOTO
Isolated and locked out
Breaker open and locked
Mechanical energy released
Assured grounding
Risk of trapped or non-isolated energy
Other
Environmental Issues
Spill mitigation, containment, or kit
Right To know Center location identified
SDS reviewed
Other
Additional Hazards
Additional Controls
List Workers Present at Time of JHA (save between each worker noted)
Signature of Workers Performing the Work
Customer Representative (first and Last Name)
Signature of Customer Representative
Visitors (first and Last Name)
Signature of Visitors That Could be Affected by This Job
Submit
Job Hazard Analysis (JHA) Form
Each job is required to complete a Job Hazard Analysis. All subcontractors must complete a Job Hazard Analysis with all crew members and visitors who enter the work area.
Should be Empty: