Blank JHA Form (Check Box Form)

COMPANY NAME: PAGE 1 OF 2
TIME:
PROJECT NAME & NUMBER:
JOB BRIEFING / ROUTINE JOB HAZARD ANALYSIS (JHA) FORM

Complete with work crew at job-briefing before beginning work; Have all affected personnel sign-off in Block 9 of this form.
(1) JOB INFORMATION
Date: Job Name: Job Number:

Physical Address: Longitude: Latitude: Supervisor/Crew Lead:
(2) EMERGENCY PROCEDURES (LIST TELEPHONE NUMBERS AND ATTACH DIRECTIONS TO THE SITE.)
Are 911 systems functional with cell phone use? Yes No
Fall Protection Rescue Procedures to Fire Department In-House Crew (Crew must be properly trained in rescue) Other: Please describe.
be used:
Ambulance: Fire: Police:
Local Hospital: Telephone Co: Utility Co:
Evacuation Point: Superintendent & Cell Phone: Safety & Cell Phone:
(3) JOB / TASKS FOR TODAY (Note: Any rigging with a payload weight of 10T - 50T = Medium Lift; or > 50T= Heavy Lift; or a Critical Lift requires the
submittal of an Engineer approved lift plan as required per contract requirements.)
CHECK TYPE OF WORK BEING PERFORMED:
Working at Height > 6 feet Electrical Construction Civil/Concrete/Masonry Scaffolding
Heavy Lift (>50T), Incidental Lift (<10T) Welding Heavy Equipment Decommissioning Other:
(4) JOBSITE EXPOSURES, NOTE: ELECTROMAGNETIC INTERFERENCE (EMI), RADIO FREQUENCY (RF)
Hazard Identification: Items checked below relate to existing conditions or may be a result of site operations
Physical Hazards Health Hazards
Confined Space Permit Required Struck by/Contact With Chemical Exposure Silica Exposure (Concrete/Stone
Electrical Overhead Work Cold Stress Cutting)
Elevation / Site Terrain Slips, Trip, or Falls EMI/RF/Radiological/Laser Biological Hazards: Animals, Avian,
Falls from Elevations Underground Utilities Heat Stress Insects, Microbiological, etc.
Fire Hazards Vehicle Traffic High Noise (>85 dBA) Asbestos, Lead
Heavy Equipment Other: Lifting Hazards Other:
(5) HAZARD CONTROL MEASURES
PPE and Monitoring Equipment Inspections Safety Systems / Training

(Complete All Prior to Use)
Fall Protection Tools/Equipment Barricades, Pedestrian Shelters, Banner of Notices, PPE, and Warning Signs)
Gloves Rigging Excavation & Trenching Plan/Log
Hard Hat Housekeeping Lock-Out / Tag-Out
Hearing Tag Lines Job Briefing Meeting
Respirators Ground Fault Protection Pre-Approved Plans (Critical Lifts, Roped-Access, Suspended Personnel Lift)
Hazmat Suits; Level: D, C, B, A Cranes Color Coded Inspection Schemes for Rigging, Equip., Electrical Cords &
Safety Glasses, Goggles, Face Shield Hoists Tools; Annotate Colors, Items, & Frequency.
Safety Vest: Class 1, 2, 3 Other: Uniform Traffic Control
Air Monitoring: Permit Systems:
Oxygen Deficiency (< than 19.5%) Confined Spaces: Is a Permit Required? o Yes Obtained o
Oxygen Enrichment (> than 23.5%) Electrical Work: Is a Permit, Outage, or Clearance Required?o Yes Obtained o
Flammable Gases/Vapors (> than 10% of LEL) Fire, Smoke, Heat Alarms Deactivation: Are Permits Required? o Yes Obtained o
Airborne Combustible Dust (> than LFL) Welding/Hot/Burning: Is a Permit Required? oYes Obtained o
Toxic Gases or Vapors (> than PEL)
Pressure/Chemical Pipe Opening: Is a Permit Required? o Yes Obtained o
Noise Monitoring:
Egress Evacuation Routes Altered: Is a Permit Required? o Yes Obtained o
Laser Safety:
Other:
Other:
NOTE: Notify and confirm proper procedures, mitigation and/or protective steps taken with the designated Safety Representative before entering: any trench or any
general excavation that is greater than 5’ deep; or any Confined Space.
(6) COMPLETE FOR CIVIL WORK (PLEASE NOTE: ENGINEER APPROVED TRENCHING PLAN REQUIRED FOR TRENCHES > 5’)
1. Describe type and depth of excavations Type A Soil/Rock Type B Soil/Rock Type C Soil/Rock:
REV: 0, 03/26/09
COMPANY NAME: PAGE 2 OF 2
TIME:
PROJECT NAME & NUMBER:
JOB BRIEFING / ROUTINE JOB HAZARD ANALYSIS (JHA) FORM

2. Cave-in / Engulfment control measures to be used if excavation will be greater than 5 feet and personnel are entering the trench. Sloping Benching
Shoring Trench Shield/Box Ladder in Trench > 5 Feet & Every 25’ Sump Pump LOTO:
3. Describe elevation/site terrain/environmental concerns or hazards:
4. Describe hazards with site/vehicle access (High Traffic, Heavy Haul, Boom Cranes, and storage of materials/HazMat:
5. Describe the type of electrical or gas concerns or hazards (e.g. Electrical/Gas/Fiber Optic Lines):
(7) FALL PROTECTION & USING SUSPENDED PERSONNEL PLATFORM (Complete for Working at heights and Roped-Access)
Type of Elevated Work & Height: Type of Tower or Building:
Describe the fall protection system to be used when working aloft. Lifeline Personal Fall Arrest Safety Monitor Qualified Climber Safety Net
Ladder Safety Device Roped Access (Requires Roped Access JHA):
Fall protection to be used. Full Body Harness One Lanyard Two Lanyards (100%) Rope Grab Cable Grab Retractable Lifeline Ropes
Ascenders/Descenders Anchorage Points, Belay, & Straps:
Has each employee inspected his or her fall protection equipment? Yes No
Hoisting Equipment to be used: < 20’ Encroachment of Power Lines, Yes No; If yes, ID Voltage _______KV; De-energize/Test/Ground Lines Yes No
Suspended Personnel Platform/basket Forklift Platform Crane/Boom/Aerial Truck Scissor/Snorkel Lift Gin Pole Roped Access
Suspended Personnel Platform Checklist and/or Critical Lift Plan Completed? Yes No
(8) REVIEWS AND SIGNATURES
GC Superintendent /Foreman Lower-tier Subcontractor Supervisor

Name Signature Name Signature
(9) PROJECT PERSONNEL ACKNOWLEDGEMENT (ALL AFFECTED PERSONNEL SIGN AFTER JOB BRIEFING)
Name: Company: CPR / First Aid Name: Company:

Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes Yes
REV: 0, 03/26/09

Blank JHA Form (Check Box Form)

Uploaded by

Copyright:

Available Formats

Blank JHA Form (Check Box Form)

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Blank JHA Form (Check Box Form)

Uploaded by

Copyright:

Available Formats

COMPANY NAME: PAGE 1 OF 2

PROJECT NAME & NUMBER:

JOB BRIEFING / ROUTINE JOB HAZARD ANALYSIS (JHA) FORM

Date: Job Name: Job Number:

(5) HAZARD CONTROL MEASURES

PPE and Monitoring Equipment Inspections Safety Systems / Training

PROJECT NAME & NUMBER:

JOB BRIEFING / ROUTINE JOB HAZARD ANALYSIS (JHA) FORM

Type of Elevated Work & Height: Type of Tower or Building:

GC Superintendent /Foreman Lower-tier Subcontractor Supervisor

Name: Company: CPR / First Aid Name: Company:

You might also like