JHA WORKSHEET

• Unit

  Select

• Location: (Facility/Room)

• Conducted on

  Date

• JHA Title/Name

• Job/Task/Project Description:

• Does this job/project have a Technical Order or Job Guide?

  Yes

  No

• Provide TO or Job Guide number:

• Does this job/project involve the operation of machinery or equipment?

  Yes

  No

• Do you have the operators manual for the machinery/equipment to be used?

  Yes

  No

• Provide location of Operators Manual or upload if digital:

• Is any of the job/project steps/tasks being performed in a "Confined Space"?

  Yes

  No

  Unknown

  Definition of "Confined Space"

• Will the job/project involve working over dangerous equipment or machinery, or from an elevated location of 4ft or more?

  Yes

  No

• Does the job/project involve the servicing or maintenance of machinery and/or equipment where the unexpected energization, start up or release of any stored energy, could harm employees? (Energy sources are not limited to Gravity, Hydraulic, Electrical, Wind, etc.)

  Yes

  No

  Unknown

  Definition of "Confined Space"

• Has a Fall Hazard Assessment been completed?

  Yes

  No

• Will the job/project involve working with chemicals or hazardous materials?

  Yes

  No

  Unknown

  Definition of "Confined Space"

• REQUIRED TRAINING/CERTIFICATIONS

  Yes

  No

  Unknown

  Definition of "Confined Space"

• List required training or certifications:

PERSONAL PROTECTIVE EQUIPMENT (PPE)

PPE

• PPE TYPE and DESCRIPTION

  Select Mechanics glove Safety Glasses Goggles (Splash Protection) Goggles Debris Face Shield Leather Work Gloves Nitrile Rubber Gloves Cut Resistant Gloves Steel Toe Boots Composite Toe Boots Metatarsal Protection Hearing Protection Respirator Filtering Face Piece Full Body Harness Fall Restraint Lanyard Self Retracting Lanyard Rescue Tripod and wench Other

  • Mechanics glove
  • Safety Glasses
  • Goggles (Splash Protection)
  • Goggles Debris
  • Face Shield
  • Leather Work Gloves
  • Nitrile Rubber Gloves
  • Cut Resistant Gloves
  • Steel Toe Boots
  • Composite Toe Boots
  • Metatarsal Protection
  • Hearing Protection
  • Respirator
  • Filtering Face Piece
  • Full Body Harness
  • Fall Restraint Lanyard
  • Self Retracting Lanyard
  • Rescue Tripod and wench
  • Other

• List Other PPE:

• Has Bioenvironmental or Safety office reviewed PPE Selection?

  Yes

  No

BASIC STEPS

• Instructions
Step

• BASIC STEP/ACTIVITIY:

• POTENTIAL HAZARDS:

• CONTROLS TO REDUCE OR ELIMINATE HAZARD:

• Attachments:

  Media

• ANALYSIS COMPLETED BY: LAST NAME, FIRST

  Sign
REVIEWER/APPROVER:

• LAST NAME, FIRST/ WORKCENTER:

  Sign