MSS-IN Maintenance/Supervisor/GL JHA for Normal or Abnormal Work

• Conducted on

  Date

• Prepared by

• Location
  Address

• Write jobs steps below.

  Yes

  No

  N/A

• Is this a Normal or Abnormal process?

  Yes

  No

  N/A

Lacerations

Punctures

Strains (Back)

Sharp Edges

Moving Equipment

Pinch Points

Slips/Trips/Falls

Lighting

Falls

Housekeeping

Flammable Liquids or Gases

Lockout/Tagout Issues

Confined Space Entry

Forklift Operation

Overhead Crane Operation

Loading/Unloading Trailers

Other

• Forklift Operation

• Overhead Crane

• Lockout/Tagout

• Machine Operation

• Non Permit Required -Confined Space Entry

• Hard Hat

• Cut Resistant Gloves

• Hyflex

• Cotton Sleeves

• Kevlar Sleeves

• Steel Toed Boots

• Safety Glasses

• Face Shield

• Do workers have to stretch to reach things

  Yes

  No

  N/A

• Direct Pressure on hands

  Yes

  No

  N/A

• Are excessive forces needed

  Yes

  No

  N/A

• Poor posture is required to complete some tasks

  Yes

  No

  N/A

• Excessive bending past 30 degrees

  Yes

  No

  N/A

• Work tables are a standard size

  Yes

  No

  N/A

• Oil or hydrolic fluids handled on this job?

  Yes

  No

  N/A