Job Hazard Analysis

• JHA - Foreman - Project Site

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

• Prepared by:

  Select Richard Dickinson Anthony Beverly Hugh French Scott Taylor Michael Wright James Brown Lee Ratliff Jason Corbin Michael Dwyer Joe Bailey Chuck Ayers James Shifflett Christopher M. Cole Joshua Shifflett Tom Chestnut Sudip Umachigi Gary Berghan Clyde Eppard Mark A. Davis Tom Manley II

  • Richard Dickinson
  • Anthony Beverly
  • Hugh French
  • Scott Taylor
  • Michael Wright
  • James Brown
  • Lee Ratliff
  • Jason Corbin
  • Michael Dwyer
  • Joe Bailey
  • Chuck Ayers
  • James Shifflett
  • Christopher M. Cole
  • Joshua Shifflett
  • Tom Chestnut
  • Sudip Umachigi
  • Gary Berghan
  • Clyde Eppard
  • Mark A. Davis
  • Tom Manley II

• Document No.

• Conducted on

  Date

Project site information

• Project name:

• Task activity:

• Work being performed for:

• 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

• List

  Yes

  No

  N/A

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:

• JHA Prepared by

  Select Richard Dickinson Anthony Beverly Hugh French Scott Taylor Michael Wright James Brown Lee Ratliff Jason Corbin Michael Dwyer Joe Bailey Chuck Ayers James Shifflett Christopher M. Cole Joshua Shifflett Tom Chestnut Sudip Umachigi Gary Berghan Clyde Eppard Mark A. Davis Tom Manley II

  • Richard Dickinson
  • Anthony Beverly
  • Hugh French
  • Scott Taylor
  • Michael Wright
  • James Brown
  • Lee Ratliff
  • Jason Corbin
  • Michael Dwyer
  • Joe Bailey
  • Chuck Ayers
  • James Shifflett
  • Christopher M. Cole
  • Joshua Shifflett
  • Tom Chestnut
  • Sudip Umachigi
  • Gary Berghan
  • Clyde Eppard
  • Mark A. Davis
  • Tom Manley II

• JHA Prepared by

  Sign

• Safety Manager's Signature:

  Sign