JHA

• Hazard Analysis Number

• Client / Site

• Conducted on

  Date

• Prepared by

• Employees Involved

• Job Being Assessed

• Job Task

• Picture of Task

  Media

• Where does the task occur?

• Are there hazards associated with the job?

  Yes

  No

  N/A

Hazards Identified

• Hazard Identification

Hazard

• Other Contributing Factors

Hazard Controls

• Can the hazards be eliminated?

  Yes

  No

  N/A

• Engineered Controls

Engineered Control

• Are all hazards able to be eliminated?

  Yes

  No

  N/A

• Hazards Not Eliminated

Hazard

Personal Protective Equipment

• Is Personal Protective Equipment needed?

  Yes

  No

  N/A

• Gloves

• Goggles

• Respirator

• Long Sleeves

• Pants

• Work Boots

• Apron

• Hard Hat

• Body Harness

• Arc Flash Protection

• Other

Procedure to Complete:

• Evaluated Steps to Complete Task

Step

• Employees

Signature

• Add signature

  Sign