Site Information
-
Site conducted
-
Conducted on
-
Prepared by
-
Job / Permit No.
-
Job Description
-
Identify the most serious POTENTIAL injury for the task being performed (i.e. crushing, entanglement, electrocution etc.).
Pre-Job Review
-
Have all relevant procedures, standards, guidelines or safe work practices been reviewed?
-
Procedures or work practices been modified to perform this work? (MOC required)
-
Has all teammate's safety training relevant to the Scope of Work been reviewed?
-
Have all teammates completed all required trainings for the tasks being performed?
PPE Required During This Task
-
Select all the PPE required during this task.
- Hard Hat
- Bump Cap
- Safety Shoes / Boots
- Safety Glasses
- Goggles
- Face Shield
- Hearing Protection - Single
- Hearing Protection - Double
- Respirator
- Fall Protection
- Fall Restraint
- Safety Vest
- Work Vest
- Flame / Arc Resistant Clothing
- Gloves - Cotton
- Gloves - Leather
- Gloves - Impact Protection
- Gloves - Cut Resistant
- Gloves - Chemical Resistant
- Gloves - Latex / Nitrile
- Chemical Resistant Suit
- Chemical Apron
- Protective Clothing
- Other
-
Please list all "other" PPE that is required.
Pre-Job Hazard Assessment Form
-
Use this form to assist in identifying the relevant hazards that are present throughout the job and incorporating the applicable hazard controls into the hazard management section of the JHA.
-
**This table does not include all possible hazards. It is expected that the required PPE for the activity and working conditions will be used.**
-
Confined Space hazards exist?
-
Select all that apply.
- Discuss confined space entry safe work practices
- Monitor access or entry
- Protect surfaces from inadvertent contact
- Provide observer
- Develop rescue plan
-
Emergency Response hazard exist.
-
Select all that apply.
- Keep egress routes clear of obstructions
- Keep safety shower(s) and eye wash station(s) accessible
- Have a rescue plan in place
- Keep all fire extinguishers, first aid supplies and shutdown locations unobstructed and accessible to all teammates
-
Equipment Hot or Cold hazard exist.
-
Select all that apply.
- Heat or cool equipment before work starts
- Install barriers
- Provide warning signs
- Implement cold temperature and brittle failure controls
- Wear thermal gloves or other PPE
-
Equipment and Tool hazards exist.
-
Select all that apply.
- Inspect equipment and tools
- No use of modified tools
- Use protective guards
- Use correct tools and equipment for task
- Protect or remove sharp edges
-
Excavation hazards exist.
-
Select all that apply.
- Have an excavation plan or safe work practice
- Locate underground pipes
- Locate underground utilities
- De-energize underground services
- Implement confined space procedures
- Trench safety work practices
-
Falling or Dropped Objects hazard exist.
-
Select all that apply
- Use signs and barriers to restrict entry or access under work at elevation
- Use lifting equipment to raise tools to or from the work location
- Secure tools (tie off)
-
Hazardous Substance hazard exists.
-
Select all that apply.
- Follow SDS controls
- SDS on-site for each hazardous chemical / substance
- Implement health hazard controls (lead, asbestos, silica)
- Test or analyze material
-
High Energy or High Voltage hazard exist.
-
Select all that apply.
- Restrict access to authorized personnel only
- Discharge equipment and make electricity dead
- Observe safe work distances for live cables
- Use flash burn PPE suit
- Use insulated gloves, tools or mats
-
High Noise hazard exist?
-
Select all that apply.
- Wear correct hearing PPE
- Manage exposure times
- Shutdown equipment
- Use "quiet" tools
- Sound barriers or curtains
- Provide or use suitable communication techniques
-
Ignition Sources hazard exist.
-
Select all that apply.
- Remove, isolate, or contain combustible materials
- Provide firefighting equipment
- Construct a fire-safe habitat
- Provide a fire watch during and after hot work activities
- Conduct continuous gas testing
- Bond or earth for static electricity or cathodic protection
-
Lifting Equipment hazard exist.
-
Select all that apply.
- Confirm lifting equipment condition and certification
- Obtain approval for lifts over processing equipment
- Have a documented and approved lift plan
-
Manual Handling hazard exist.
-
Select all that apply.
- Assess manual handling task(s)
- Limit load size
- Manage posture
- Confirm stability of load and work platform
- Get assistance or mechanical aid to avoid pinch points
- Ergonomic assessment needed
-
Mobile Equipment hazard exist.
-
Select all that apply.
- Assess equipment condition
- Implement controls on users or access
- Limit and monitor proximity to live equipment or cables
- Manage overhead hazards
- Adhere to road and site rules
- Manage operator certifications
-
Moving Objects or Equipment hazard exist.
-
Select all that apply.
- Confirm machinery guard integrity
- Provide protective barriers
- Observer to monitor proximity of people and equipment
- Shut down or lockout equipment
-
Other Energy Sources hazard exist.
-
Select all that apply.
- Spring compression or expansion control
- Implement electromagnetic (radio) controls
- Manage pressure vacuum
- Manage heat generating processes
-
Modifications hazards exist.
-
Select all that apply.
-
Personnel hazard exists.
-
Select all that apply.
- Provide induction or training for new workers
- Mentor, coach, or supervisor
- Verify competencies, skills, and experience
- Address applicable limitations (fatigue, exhaustion, and restricted duty)
- Manage multiple languages
- Provide on-the-job training
-
Poor Lighting or Visibility hazard exist.
-
Select all that apply.
- Provide alternate lighting
- Wait or defer until lighting improves
-
Portable Electrical Equipment hazard exist.
-
Select all that apply.
- Inspect equipment for condition and test date currency
- Implement continuous gas testing
- Protect electrical leads from impact or damage
- Ensure GFCIs
-
Potential Spill hazard exist.
-
Select all that apply.
- Provide spill containment
- Have spill clean-up supplies
- Restrain and isolate
-
Pressurized Equipment hazard exist.
-
Select all that apply.
- Perform isolation - LOTO
- Depressurize, drain, purge, and vent
- Relieve trapped pressure
- Anticipate residual pressure or fluids
-
Radiation hazard exist.
-
Select all that apply.
- Use barriers and signs to restrict access
- Notify personnel who may be affected
- Implement controls
- Conduct RAD testing
-
Slip, Trip and Fall hazard exist.
-
Select all that apply.
- Identify and shield uneven surfaces
- Secure or cover cables, cords, and tubing
- Clean up liquids
- Barricade or rope-off openings and holes
-
Vibrating Equipment hazard exist.
-
Select all that apply.
- Manage exposure times
- Assess effect of vibration on equipment
- Use low vibration equipment
- Apply noise controls
-
Waste Clean Up and Disposal hazard exist.
-
Select all that apply.
- Apply environmental management practices
- Follow site waste management procedures
- Clean up equipment and material at site
- Optimize task to minimize waste production
-
Weather hazards exist.
-
Select all that apply.
- Implement controls for slippery surfaces
- High winds - blowing debris, blowing equipment and/or supplies
- Heat - hydration, breaks
- Cold - PPE, heaters
- Lightening - defer work
-
Work at Heights hazard exist.
-
Select all that apply.
- Discuss working at heights safe work practices
- Verify fall restraint and arrest equipment certification
- Verify employee's competency when using fall prevention systems
- Set up fall rescue devices prior to work beginning
- Fall rescue plan
-
Other hazards not listed.
-
Please list.
Hazard Management
-
If the Scope of Work or the conditions change significantly, STOP THE WORK and revise the JHA to address the hazards before proceeding.
-
Step 1
-
Task to be performed (what are you doing?)
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 2
-
Task to be performed (what are you doing?)
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 3
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 4
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 5
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 6
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 7
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 8
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 9
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 10
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 11
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 12
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 13
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 14
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 15
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 16
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 17
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 18
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 19
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 20
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 21
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 22
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 23
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 24
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 25
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 26
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 27
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 28
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 29
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
-
Are there more steps for the above task?
-
Step 30
-
Task to be performed.
-
Potential hazards (what could go wrong?)
-
Hazard controls (How can harm be prevented?)
-
Assigned person(s) to complete the task.
Participation
-
Have all teammates participated in the review of the JHA?
-
List the names of the teammates that reviewed and participated in the JHA.
-
All teammates have the authority to stop work if they identify a potential safety hazard. No work shall resume until the hazard has been properly addressed and resolved.
