JHA

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date & Time of JHA.... Must be done before the start of any work

  Date

Equipment

• Equipment or Tools being Used?

• Daily Equipment Checklist Done for Equipment?

  Yes

  No

  N/A

• Picture of Equipment

  Media

Man Power

• Supervisor/Foreman

• Phone #

• Emergency Contact Name

• Phone #

• How many guys are in the crew today?

Daily Task

• Work In Progress? (Who, What, Where, When, Why)

• Photos of Jobsite

  Media
• Where is the work taking place?
  Address

• Safe Plan to Eliminate/Correct Hazards? (At least 3 ways to eliminate each hazard)

• What are the Task being performed today?

• What are the hazards associated with the task? (At least 3 hazards associated with each task)

Worker Concerns or Ideas?

• List worker concerns and ideas to help improve safety for future follow-up

Signature of All Working

• Name Of Signature

  Sign

• Name Of Signature

  Sign

• Name Of Signature

  Sign

• Name Of Signature

  Sign

• Name Of Signature

  Sign

• Name Of Signature

  Sign

• Name Of Signature

  Sign

• Name Of Signature

  Sign

• Name Of Signature

  Sign

• Name of Signature

  Sign