Title Page
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Conducted on
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Prepared by
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Location
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This document is to be used as information resource and to identify and mitigate all hazards associated with the task to be performed. Any change in scope, additional identified hazards, or stop work event will require a new JHSA to be completed before work commences on this task.
GENERAL JOB INFORMATION
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SUPERVISOR
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CREW MEMBERS
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Job Number
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PLANT EMERGENCY NUMBER
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LOCATION OF NEAREST PHONE
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EVACUATION AREA
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EMERGENCY ALARMS REVIEWED
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HAS NEAREST EMERGENCY SHOWER/EYE WASH STATION FOUND
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Date and Time
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Detailed Job Description
PLEASE LIST DETAIL PRE-JOB TAILGATE SAFETY TOPICS. THESE TOPICS NEED TO BE SPECIFIC TO THE JOB BEING PERFORMED. EXAMPLES: IF THE TOPIC IS SLIPPERY SURFACES THEN NOTE AS "MATERIAL ON FLOOR IS SLICK AND CAN CAUSE A FALL" IF TOPIC IS PINCH POINTS THEN NOTE "WORKING AROUND THE CONVEYOR BEWARE PINCH POINT BETWEEN WHEEL AND BELT"
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Hydroblasting
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Are all whip checks in place?
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If lancing is anti-withdrawal device in place
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Explain why anti-withdrawal device is not present
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If lancing, is stinger/nozzle combination 1.5 times the diameter of the pipe/tube
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Explain why stinger/nozzles in not 1.5 times the ID of pipe/tube.
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Dry Vacuuming
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Is the vacuum break in place?
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Does vacuum truck have proper tail hose?
HAZARD IDENTIFICATION AND PPE
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POTENTIAL SAFETY HAZARDS (SELECT ALL THAT APPLY)
- FALL FROM HEIGHTS OR SAME LEVEL
- SLIPPERY OR UNEVEN SURFACES
- HEAVY LIFTING
- TRAFFIC (PEDESTRIAN OR VEHICLE)
- CONFINED SPACE
- ENGULFMENT
- HEAT/COLD EXPOSURE
- INCLEMENT WEATHER
- ELECTROCUTION
- REACTIVITY
- CHEMICAL BURN
- INHALATION/INGESTION
- OVER HEAD WORK
- NOISE
- FLAMABILITY
- OTHER
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SAFETY EQUIPMENT (SELECT ALL THAT APPLY)
- TRIPOD
- LIFELINE
- WRISTLET
- HARNESS
- PERSONAL AIR MONITOR
- 4 GAS CONFINED SPACE MONITOR
- ESCAPE RESPIRATOR
- FULL FACE RESPIRATOR (AIR PURIFYING)
- FULL FACE RESPIRATOR (SUPPLIED AIR)
- SELF RETRACTING LIFELINE (SRL)
- OTHER
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PLEASE LIST OTHER SAFETY EQUIPMENT
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PLEASE LIST OTHER SAFETY EQUIPMENT
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IF PERSONAL MONITOR IS NEED PLEASE SELECT ALL THAT APPLY
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PPE REQUIREMENTS
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BLAST BOOTS
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RUBBER BOOTS
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FACESHIELD
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CHEMICAL GOGGLES
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SEALED SAFETY GLASSES
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LONG SLEEVES
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FRC CLOTHING
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RAIN SUIT
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CHEMICAL SUIT
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TYVEK
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LEVEL A SUIT
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LEVEL B SUIT
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CHEMICAL GLOVES
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(HARD HAT SAFETY GLASSES HIGH VIZ VEST LEATHER GLOVES STEEL TOED BOOTS EAR PLUGS ARE MINIMUM PPE REQUIREMENTS)
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CUT RESISTANT GLOVES
SUPERVISOR AND CREW RESPONSIBILITIES
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PRE-JOB START UP QUESTIONS
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HAS A PRE JOB SAFETY MEETING BEEN HELD WITH EMPLOYEES?
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HAS THE WORK AFREA BEEN BARRICADED TO LIMIT ACCESS?
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HAS THE SUPERVISOR LOCKED AND TAGGED OUT ANY INVOLVED
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IF WORK AREA IS A CONFINED HAS THE AIR BEEN TESTED AND ENTRY PERMIT BEEN CORRECTLY COMPLETED AND POSTED?
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HAS ALL VEHICLE EQUIPMENT BEEN PROPERLY CHOCKED AND SPILL PADS AVAILABLE FOR LEAKS/SPILLS?
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POST JOB QUESTIONS
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HAS ALL ENVIROVAC EQUIPMENT BEEN INVENTORIED, CLEANED, AND RETURNED?
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HAVE ALL LOTO LOCKS BEEN REMOVED?
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HAVE ALL TRUCKS AND PUMPS BEEN PROPERLY DECONTAMINATED?
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HAS THE WORK SITE BEEN CLEANED?
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SUPERVISOR
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CREW MEMBER
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CREW MEMBER
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CREW MEMBER
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CREW MEMBER
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CREW MEMBER
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CREW MEMBER
