JHA Form | IP Solutions

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Leading provider of General Contracting

Consulting Services and Project Management Solutions

JOB HAZARD ANALYSIS

Complete a new JHA at he beginning of each shift.

Select a date

Time

Name filling out form

Competent Person on Site

Foreman

Job Number and Exact Location

Subcontractor on Site

Subcontractor participated in JHA

One Call Ticket No.

Nearest Medical Facility

Have Emergency Actions been Discussed?

One Call Effective Date

One Call Expiration Date

Specefic work to be performed today:

Job Task Step #1

Job Task Step 1 : Potential Hazards

Job Task Step 1 : Methods to Address Hazards

Job Task Step 1 : Individual(s) Assigned

Job Task Step #2

Job Task Step 2 : Potential Hazards

Job Task Step 2 : Methods to Address Hazards

Job Task Step 2 : Individual(s) Assigned

Job Task Step #3

Job Task Step 3 : Potential Hazards

Job Task Step 3 : Methods to Address Hazards

Job Task Step 3 : Individual(s) Assigned

Job Task Step #4

Job Task Step 4 : Potential Hazards

Job Task Step 4 : Methods to Address Hazards

Job Task Step 4 : Individual(s) Assigned

Job Task Step #5

Job Task Step 5 : Potential Hazards

Job Task Step 5 : Methods to Address Hazards

Job Task Step 5 : Individual(s) Assigned

Job Task Step #6

Job Task Step 6 : Potential Hazards

Job Task Step 6 : Methods to Address Hazards

Job Task Step 6 : Individual(s) Assigned

Job Task Step #7

Job Task Step 7 : Potential Hazards

Job Task Step 7 : Methods to Address Hazards

Job Task Step 7 : Individual(s) Assigned

Job Task Step #8

Job Task Step 8 : Potential Hazards

Job Task Step 8 : Methods to Address Hazards

Job Task Step 8 : Individual(s) Assigned

Stuff That Kills You (STKY)

How are we controlling STKY?

Special Equipment Required and Safety Consideration (Check all that apply in each section)

PPE (Check all that apply)

Hard Hat

Safety Glasses/Side Shields

Googles/Spoggles

Appropriate Hand Protection

Hearing Protection

Respiratory Protection

Face Shield

Safety Vest Type-2

Safety Vest Type -3

Rain Gear

USCG Approved Life Jacket

Welding Hood

Metatarsal Foot Covers

ANSI Approved Work Boots

Fall Protection

FR Clothing

Dielectric Boots

Dielectric Gloves

Traffic Control (Check all that apply)

Traffic Plan

Flaggers

Arrow/Message Board

Warning Signs

360 Walk-A-Round

Wheels/Chocks

Cones

Back Up Alarms

Spotters

Excavation (Check all that apply)

OSHA Notifications

Pre-Dig Forms

Shoring/Trench Box

Tab-Data/Shoring Design

Ladders

Soil Analysis Checklist

Atmosphere Testing

Trench Entry Form

Confined Space (Check all that apply)

Entry Permit

Air Monitor

Air Blower

Rescue Equipment

SDS Available

Heat Illness Prevention (Check all that apply)

Drinking Water

Shade/Canopy In-Place

Rest Room - On Site & Secured

Rest Room - Off Site

Hand Tools (Check all that apply)

Guards in Place

Steel Plate Tool/Tagline

RPMsMatch Grinder Wheels/Discs

GFCI Protected

Cords Inspected

Concrete Cutting Water Supply

Emergency (Check all that apply)

Emergency Response Plan Onsite

Fire Extinguisher

Safety Shower/Eye Wash

Equipment Onsite (Check all that apply)

Side Boom Certified Operator

Fork Lift/High Reach Forks Certified Operator

Crane/Knuckle Boom Certified Operator

Rigging Certified/Inspected

Signal Person Certified

Lockout/Tagout (Check all that apply)

Lock with ONE key

Warning Tags

Additional (Check all that apply)

First Aid / CPR Certified Person

Spill Kits

Goalposts/OHP Signs

I verify that my crew has been given the above information and that they have indicated an understanding of the job description, job task, job hazards and risk mitigation, their roles and responsibilities, and have all required PPE. Also, I agree to immediately STOP all operations at the first sign of job deteriorations, personnel changes, equipment misapplication or failure,communication issues or any other condition or issue which places my crew, my visitors, thepublic, or myself at undue risk.

Foreman/Superintendent Signature

List all staff names that are present on the job site here along with their vehicle number driving.

Additional Comments:

Equipment Damaged:

Yes

No

Equipment #

Anyone injured today

Yes

No

Brief Description

JHA Sign off that the job site was left cleaned and secured. (All staff that closed job site needs to initial below)

I verify the job site was left clean and secure.

I verify the job site was left clean and secure.

I verify the job site was left clean and secure.

I verify the job site was left clean and secure.

Thanks for submitting! Make it a great day today!

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