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.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Name
*
First Name
Last Name
Your Email Address
*
You will receive an editable copy of this JHA upon submission
Your Phone Number
*
-
Area Code
Phone Number
Supervisors Email
*
Your supervisor will receive a copy of the JHA
Supervisors Email
Your supervisor will receive a copy of the JHA
Supervisors or the Client Email
Your supervisor will receive a copy of the JHA
Who is your Field Safety Manager
*
JJ John Bland, 304-627-8891
"Catfish" William Watford, 850-851-9574
Damone Gasaway, 713-906-3917
Mike Washington, 248-296-1388
Client Name
Project Site
*
Location
*
City, State or County, State
Indicate the weather conditions
*
Clear and Sunny
Partly Cloudy
Overcast
Rainy
Snowing
Sleeting
Fog
Indicate the basic weather conditions
Indicate the Temperature
*
90 Degrees plus & humid
90 Degrees plus & Dry
70-89 Degrees
40-69 Degrees
20-39 Degrees
20 Degrees or lower
Indicate the basic weather conditions
Indicate ground conditions
*
Normal & Dry
Wet
Muddy
Frozen and Icy
Snow Covered
Dry & Dusty
Indicate the basic weather conditions
Project Manager
First Name
Last Name
Contact Phone Number
-
Area Code
Phone Number
Muster Area
In an emergency where will you evacuate to?
Emergency & Communication select method of communicating an emergency
Cell Phone
Radio
Other
Emergency Phone Number
-
Area Code
Phone Number
Job Steps, Hazards & Controls
Record the basic steps to complete your job below. List the first Job Step its associated Hazards for that step and the Mitigation of those hazards section of this form
Job to be Performed
Job Steps Hazard Identification
Job Hazards & Controls
Check all that apply and give details as needed in the section above
Work Area Hazards
Open trench in work area
Confined space concerns
Moving equipment or vehicles
Lighting levels too high/ low
Extreme heat or cold
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)
Site clearance restrictions (access permission)
Other
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
Electrical Safety
Grounding and bonding
GFCI for electric power tools
Safe distance of energized lines and equipment
Clearance requirements
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
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 varified
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 or containment
Right To know Center location identified
SDS reviewed
Other
Permits Needed for the job
None
Hot Work
Excavation
Lock Out/ Tag Out
ROW Clearance
Critical Lift
Confined Space
Other
Stop Work
*
Does each crew member understand that it is the obligation of every person to stop work if something is not right
(Optional) Take a photo of conditions or other documents
(Optional) Take a photo of conditions or other documents
(Optional) Take a photo of conditions or other documents
List Workers Present at Time of JHA
Signature of Workers Performing the Work
Customer Representative (first and Last Name)
Signature of Customer Representative
Visitors (first and Last Name)
Job site Visitors (first and Last Name)
Signature of Visitors That Could be Affected by This Job
Only YOU Can Make This Job a Safe Job!
Submit
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