Title Page
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Contractor Name:
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Responsible Foreman/Crew Leader
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Date:
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Location
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Have the requirements for special procedure, training or permits been reviewed?
Check all applicable boxes below
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Confined Space Entry
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Excavation
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Hot Work
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Lock Out/Tag Out
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Critical Lift Plan
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Lifting/Lowering
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Fire Extinquishers
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Barricades/Signs
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Hazardous Atmosphere
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Electrical Hazard
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Chemical Hazard
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Scaffolding
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Forklift
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Other:
Specific PPE; List all required:
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Hard Hat
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Safety Glasses
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Welding Shield
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Welding Screens
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Face Shield
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Hand Protection
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Fall Protection
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Hearing Protection
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Foot Protection
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Respirator
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Dust Mask
JHA Checklist
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Should either Site or Corporate Safety be involved in the planning of this job?
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Have employees been briefed on the hazards associated with this job?
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List Hazards:
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Emergency and rescue equipment located in the following areas:
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Have SDS been reviewed with employees for possible chemicals present?
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Will weather conditions affect the safe performance of this job?
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Will this job affect other employees or trades?
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Other specific instructions:
I have been briefed on the correct procedures for doing this job and fully understand the hazard and safe work methods to avoid the hazards. All INJURIES MUST BE REPORTED TO MY FOREMAN OR CREW LEADER IMMEDIATELY!
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Name:
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I have completed this job in a safe manner without damage to property or injury to myself or others.
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IF NOT, PLEASE EXPLAIN IN DETAIL BELOW
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Comments:
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I have ensured that all affected empoyees have signed in and out on this JHA and that all work was done safely and satisfactorily.
