Empire JHA Form

Job Information

• Select date

  Date

• Project Name

• Project Number

• Project Location
  Address

• Project Manager

• Phone Number

• Foreman

• Phone Number

• Safety Representative

• Phone Number

• General Contractor/Client

• GC Superintendent

• GC Superintendent Phone Number

Emergency Procedures (Contact Safety Manager for nearest Clinic/Hospital locations)

• Clinic Name and Location
  Address
• Nearest Hospital Name and Location
  Address

Give a brief description of the task at hand. Note: Any changes in task must be noted prior to commencing, and will be discussed before the task is performed.

• Task Description

• Work Steps for This Task

• Hazards Associated with Work Steps

• How Can the Hazard be Eliminated/Controlled?

• Hand Tools

  Select Spud wrench Sliver Bar Burk Bar Bull Pin/Drift Pin Sledgehammer(Beater) Hamer Wrench Steel Wedge Other Tool Inspection Current

  • Spud wrench
  • Sliver Bar
  • Burk Bar
  • Bull Pin/Drift Pin
  • Sledgehammer(Beater)
  • Hamer Wrench
  • Steel Wedge
  • Other
  • Tool Inspection Current

• What Other Hand Tools

• What is the color code?

• Power Tools

  Select Power drill Screw gun Rotary hammer Shear Wrench Gun (LeJeune Gun) Electrical Cords Vacuum Other Power Tool Inspection Current

  • Power drill
  • Screw gun
  • Rotary hammer
  • Shear Wrench Gun (LeJeune Gun)
  • Electrical Cords
  • Vacuum
  • Other
  • Power Tool Inspection Current

• What Other Power Tools

• What is the color code?

• Equipment

  Select Crane Forklift Scissor Lift Boom lift Other

  • Crane
  • Forklift
  • Scissor Lift
  • Boom lift
  • Other

• Type/Make/Model

• Type/Make/Model

• Type/Make/Model

• Type/Make/Model

• Other Equipment: Type/Make/Model

• Lifting Equipment

  Select Wire Rope Sling Synthetic Web Sling Shackles Cable Clips Turnbuckles Other

  • Wire Rope Sling
  • Synthetic Web Sling
  • Shackles
  • Cable Clips
  • Turnbuckles
  • Other

• Type

Welding / Cutting

• Welding

  Select Welding Machine (turn machine completely off before re-fueling) Welding Lead (cable free from repair within 10 ft. of electrode holder) Firewatch Required (Remove all flammables from the immediate work area to prevent fires)

  • Welding Machine (turn machine completely off before re-fueling)
  • Welding Lead (cable free from repair within 10 ft. of electrode holder)
  • Firewatch Required (Remove all flammables from the immediate work area to prevent fires)

• Cutting

  Select Oxygen Acetylene Propylene Firewatch Required (Remove all flammables from the immediate work area to prevent fires)

  • Oxygen
  • Acetylene
  • Propylene
  • Firewatch Required (Remove all flammables from the immediate work area to prevent fires)

Permits and Inspections

• Permits

  Select Hot-Work Permit Confined Space Permit Critical Lift Lift Permit

  • Hot-Work Permit
  • Confined Space Permit
  • Critical Lift
  • Lift Permit

• PPE

  Select Safety Glasses Hard hat Gloves Face Shield Hearing Protection High Visibility Shirt/Vest Foot Protection Face covering

  • Safety Glasses
  • Hard hat
  • Gloves
  • Face Shield
  • Hearing Protection
  • High Visibility Shirt/Vest
  • Foot Protection
  • Face covering

• Fall Protection

  Select Full Body Harness Beam Clamp Cable Choker(Cheater) 6’ Shock Absorbing Double Lanyard Dual Retractable Lanyard Self-Retractive SRL (Yo-Yo) Engineered Horizontal Lifeline Adequate Anchorage (Capable of Withstanding 5000 lbs.) Fall protection being used properly Employees protected from a fall 6’ above a lower level

  • Full Body Harness
  • Beam Clamp
  • Cable Choker(Cheater)
  • 6’ Shock Absorbing Double Lanyard
  • Dual Retractable Lanyard
  • Self-Retractive SRL (Yo-Yo)
  • Engineered Horizontal Lifeline
  • Adequate Anchorage (Capable of Withstanding 5000 lbs.)
  • Fall protection being used properly
  • Employees protected from a fall 6’ above a lower level

• Access

  Select Feasible Access to the Jobsite Scaffold (Properly Inspected by Competent Person) Ladder (Secured / Inspected) Scissor Lift (Qualified Operator) Aerial Lift (Qualified Operator) Personnel Basket (Inspected and Approved) Confined Space

  • Feasible Access to the Jobsite
  • Scaffold (Properly Inspected by Competent Person)
  • Ladder (Secured / Inspected)
  • Scissor Lift (Qualified Operator)
  • Aerial Lift (Qualified Operator)
  • Personnel Basket (Inspected and Approved)
  • Confined Space

Attendee

• Add signature

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