Job Hazard Analysis

• JHA - Facility

• Facility location (Drop pin for GPS and street address):
  Address

• Prepared by

• Document No.

• Conducted on

  Date

Store site information

• Store city and state:

• Photo of the facility:

  Media

• Has the smoking area been designated for use?

  Yes

  No

  N/A

• Photo of designated smoking area:

  Media

Check applicable anticipated or potential hazards

• Demolition:

  Safe

  At Risk

  N/A

• Underground tank removal/disposable/high vapors:

  Safe

  At Risk

  N/A

• Activities in or near traffic areas:

  Safe

  At Risk

  N/A

• Concrete cutting or coring:

  Safe

  At Risk

  N/A

• Mobile heavy equipment activity (excavators, dump trucks, vacuum and hydovac trucks):

  Safe

  At Risk

  N/A

• Pile driving / shoring:

  Safe

  At Risk

  N/A

• Work affecting integrity of critical controls:

  Safe

  At Risk

  N/A

• Welding, cutting, grinding:

  Yes

  No

  N/A

• Hydoblasting / sand blasting:

  Yes

  No

  N/A

• Trenching (Mechanical or by hand):

  Yes

  No

  N/A

• Clearing:

  Yes

  No

  N/A

• Rigging:

  Yes

  No

  N/A

• Airborne contaminants:

  Yes

  No

  N/A

• Other (specify) :

  Yes

  No

  N/A

Critical procedures: where work involves any of the following hazards must be incorporated into JHA

• Work at heights above 6ft:

  Yes

  No

  N/A

• Confined space entry (includes tank cleaning):

  Yes

  No

  N/A

• Electrical or mechanical lockout (live, isolation, lock out / tag out:

  Yes

  No

  N/A

• Heavy equipment lifting (cranes, boom trucks, excavators):

  Yes

  No

  N/A

• Drilling borehole / excavations (Sub-surface clearance, locates):

  Yes

  No

  N/A

• Entry into excavations/Trenches (4ft) deep:

  Yes

  No

  N/A

• Hot work (in potentially explosive atmosphere):

  Yes

  No

  N/A

Ensure all hazards identified are addressed below:

• Hazards:

Hazards

• Sequence of job, Steps in order, breaking job into manageable pieces:

• Potential hazards. (Ex. underground services, hazard zone etc.):

• Safety controls to reduce or eliminate hazard:

Tools / Equipment ( list of tools and equipment and their storage on site, if relevant to safety

• Name of tool or equipment:

• Yes

  No

• Photos of issues:

  Media

The Following PPE is Required as Part of The Work Actitivies:

• Eye protection:

  Yes

  No

  N/A

• Hearing protection:

  Yes

  No

  N/A

• Fall protection:

  Yes

  No

  N/A

• Hand protection:

  Yes

  No

  N/A

• Head protection:

  Yes

  No

  N/A

• Type 2 or 3 reflective vest:

  Yes

  No

  N/A

• Foot protection:

  Yes

  No

  N/A

• Portable gas monitor:

  Yes

  No

  N/A

• Airborne particulate monitor:

  Yes

  No

  N/A

• Other (fire retardant coveralls, breathing apparatus, etc) specify :

Outside authorities: (please list contact information for local authorities and emergency response, please list nearest medical facility along with the address and phone number).

• Please list emergency contact information other than 911 when on military installations

Disposal of designated substances, surplus, or impacted materials (disposal details, e.g when, where, how?)

• How is this being done?

Employee Acknowledgement(s):

• Person Carrying Out Work:

Please Sign to Acknowledge

• Signature

  Sign

Approval:

• Inspector:

  Sign