HMA JHA/PPE Assessment

• Location - Location of Facility

  Select

• Department

• Job/Task (Some jobs may have multiple tasks that warrant separate JHA)

• Conducted on

  Date

• Prepared by

General Area

• Which Emergency Response Drills Apply?

  Select Fire Tornado/Shelter In Place EMS/Medical Spill Control/Chemical

  • Fire
  • Tornado/Shelter In Place
  • EMS/Medical
  • Spill Control/Chemical

• Does any specialty training apply?

  Select Lockout/Tagout Confined Space Fall Protection Bloodborne Pathogens Respiratory Protection Voluntary Use of Respirators - N95 Dust Masks Forklift/Aerial Equipment Arc Flash Fire Suppression Systems Critical Equipment None

  • Lockout/Tagout
  • Confined Space
  • Fall Protection
  • Bloodborne Pathogens
  • Respiratory Protection
  • Voluntary Use of Respirators - N95 Dust Masks
  • Forklift/Aerial Equipment
  • Arc Flash
  • Fire Suppression Systems
  • Critical Equipment
  • None

• Is specialty PPE provided and utilized

  Yes

  No

  N/A

• What type of specialty PPE is required?

  Select Assigned Locks/Tags 4 Gas Meters Fall Arrest Harness Lanyard/Self Retracting Lanyard Latex/Nitrile gloves CPR Barriers PAPR Negative Pressure 1/2 or full face respirator N95 Dust Mask Arc Flash Gloves/Face shield/Suit

  • Assigned Locks/Tags
  • 4 Gas Meters
  • Fall Arrest Harness
  • Lanyard/Self Retracting Lanyard
  • Latex/Nitrile gloves
  • CPR Barriers
  • PAPR
  • Negative Pressure 1/2 or full face respirator
  • N95 Dust Mask
  • Arc Flash Gloves/Face shield/Suit

• Additional Requirements?

• Pedestrian management assessed (Review access to/from area, walkways, Slip/Trip/Fall potential, impact or caught by/from potential)

  Safe

  At Risk

  None

• What controls can be added?

• Traffic Management assessed (Review traffic ways, blind spots and accessibility)

  Safe

  At Risk

  None

• What controls can be added?

• Appropriate signage in place (Caution, Hot/Cold, Exit/Not and Exit, Eye wash/Shower, PPE, High Voltage, 1st Aid, No Smoking, Fire Extinguisher, Etc...)

  Yes

  No

  N/A

• What controls can be added?

Hazard Assessments

• Are fall hazards present? (Review working at heights, overhead fall hazards, ladders, anchor points, platform railing (top rail/mid rail/toe board), aerial lifts, step stools)

  Safe

  At Risk

  None

• What PPE is required?

  Select Fall Arrest Harness Lanyard/Self Retracting Lanyard Guard rails Ladder Working Platform Netting Hard Hat Traffic Cones or Caution Tape Other

  • Fall Arrest Harness
  • Lanyard/Self Retracting Lanyard
  • Guard rails
  • Ladder
  • Working Platform
  • Netting
  • Hard Hat
  • Traffic Cones or Caution Tape
  • Other

• Are noise levels appropriate?

  Yes

  No

  N/A

• What hearing protection applies

  Select Standard ear plugs Ear muffs Both/Double

  • Standard ear plugs
  • Ear muffs
  • Both/Double

• Is there potential for flying projectiles/eye injury/dusts?

  Safe

  At Risk

  None

• What PPE applies?

  Select Face Shield Splash/Dust Goggles Safety Glasses - Standard Safety Glasses - Specialized (I.E. Tint/Dust) Face Shield and Safety Glasses

  • Face Shield
  • Splash/Dust Goggles
  • Safety Glasses - Standard
  • Safety Glasses - Specialized (I.E. Tint/Dust)
  • Face Shield and Safety Glasses

• Are machines present and safe guarded against? (Review moving/automated equipment, fans, chains/sprockets, pinch/nip points, barriers and securement)

  Safe

  At Risk

  None

• What controls can be added?

• Is foot protection required?

  Safe

  At Risk

  None

• What PPE applies?

  Select Steel-toe boots Protective footwear non steel-toe - anti slip Toe Caps Metatarsal guards

  • Steel-toe boots
  • Protective footwear non steel-toe - anti slip
  • Toe Caps
  • Metatarsal guards

• Presence of sharp material

  Safe

  At Risk

  None

• What PPE applies?

  Select Anti-Cut Sleeves Anti-Cut Glove Lvl -5 or higher Anti-Cut Glove Lvl - 3 or higher Leather Glove Standard work glove

  • Anti-Cut Sleeves
  • Anti-Cut Glove Lvl -5 or higher
  • Anti-Cut Glove Lvl - 3 or higher
  • Leather Glove
  • Standard work glove

• Presence of thermal hazards (Hot or Cold)

  Safe

  At Risk

  None

• What PPE applies?

  Select Welding Gloves Welding Apron Welding Sleeves Thermal Sleeves Thermal Gloves Hot Gloves Spats/chaps Thermal Coat Flame Resistant Uniform Category 1 arch flash Category 2 arch flash Category 3 arch flash Category 4 arch flash

  • Welding Gloves
  • Welding Apron
  • Welding Sleeves
  • Thermal Sleeves
  • Thermal Gloves
  • Hot Gloves
  • Spats/chaps
  • Thermal Coat
  • Flame Resistant Uniform
  • Category 1 arch flash
  • Category 2 arch flash
  • Category 3 arch flash
  • Category 4 arch flash

• Presence of chemicals

  Safe

  At Risk

  None

• What PPE applies?

  Select safety glasses goggles face shield Tyvek suit splash apron latex/nitrile gloves rubber butyl gloves impervious boots

  • safety glasses
  • goggles
  • face shield
  • Tyvek suit
  • splash apron
  • latex/nitrile gloves
  • rubber butyl gloves
  • impervious boots

• Are there ergonomic hazards present? I.E.>repetition, design, height, reach, mobility, access, twisting or turning

  Safe

  At Risk

  None

• Is administrative or procedural controls being used to minimize hazard?

  Yes

  No

  N/A

Additional site hazards

• Are there any additional hazards?

  Safe

  At Risk

  None

• Other hazards in the works area include:

Final

• Certified By

  Sign

• Reviewed By

  Sign

• Date and Time

  Date

• Photos Attached

  Media