Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Untitled Page
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Date *
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JOB NUMBER *
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JOB NAME
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JHA# *
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DESCRIPTION OF WORK*
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JOB LEAD *
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DEPARTMENT/ GROUP NAME *
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ELECTRICAL
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REQUIRED PERSONAL PROTECTIVE EQUIPMENT FOR ENTIRE JOB
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SAFETY GLASSES
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HEARING PROTECTION
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LADDER
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ARC FLASH PPE
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Boom lift
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SAFETY SHOES
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GOGGLES
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ELECTRICAL GLOVES
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HARNESS
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Scissor lift
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HARD HATS
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FACE SHIELD
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GLOVES
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WELDING HELMET
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OTHER
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SAFETY VEST
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LOTO
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LEATHER GLOVES
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AIR MONITOR
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OTHER LIST:
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ANY YES ANSWER WILL REQUIRE CORRECTIVE ACTION PRIOP TO COMMENCEMENT OF WORK
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Potential Hazards
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Choose one
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Corrective Actions
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Slips/ trips/ falls
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Struck by/ Contact with
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Cuts/ scrapes/ bruises
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Lifting/ twisting/ strains
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Energized equipment
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Electrical shock
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Vehicle traffic
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Arc flash
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Fire hazards
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Permit required (list type)
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Overhead work
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Confined space
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Underground utilities
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Other hazards
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Other hazards
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I have reviewed the area for potential Hazard(s). All items verified to be corrected prior to start of work. There may be other hazards identified as described above. I understand I have the authority and responsibility to stop work I believe to be unsafe
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Worker Name (print)
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Signature
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I have reviewed the area for hazards & controls described in this JHA with all workers listed above and authorize them to perform the work. Workers are qualified (i.e. licensed or certified, as appropriate) to perform this activity
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Supervisor (print) *
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Signature
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I (client) have communicated area hazards with the supervisor or listed worker(S) for this activity and have coordinated the described activity with affected occupants. The above listed workers are released to perform work in the following area(s):
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Additional Comments
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Area or Building Manager (print)
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Signature
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CLEAR FORM
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EMAIL
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PRINT
