Blank JHA Form (Check Box Form)
Blank JHA Form (Check Box Form)
Blank JHA Form (Check Box Form)
TIME:
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:
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:
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)
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
(9) PROJECT PERSONNEL ACKNOWLEDGEMENT (ALL AFFECTED PERSONNEL SIGN AFTER JOB BRIEFING)
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes Yes
REV: 0, 03/26/09