SafetyNet PPE Assessment JHA - Rev 2

• Document No.

• Assessment Title

• Client / Site

• Conducted on

  Date
• Location
  Address

• Analyst

• Summary statement

• Number if job task reviewed

Job hazard analysis

• Each individual hazard assessment is listed as "Elements" each assessment assumes engineering controls are in place first and PPE is recommended only when engineering and administrative controls cannot eliminate the hazards.

Job task

• Job task pictures

  Media

• Task description

• Job location/s

• Hazards associated with this task

• Add media

  Media

• Measurements or Baselines

• Severity of a potential injury

  Select Life threatening / serious injury / long term injury / Acute injury /

  • Life threatening /
  • serious injury /
  • long term injury /
  • Acute injury /

• Can the hazard be minimized through administrative controls

  Yes

  No

  N/A

• List administrative controls

• Can the hazard be eliminated or reduced with engineering controls?

  Yes

  No

  N/A

• Controls required or recommended

• Add media

  Media

• Drawings

  Drawing

• Parts of the body requiring protection

  Select Hands-- Eyes-- Face-- Ears-- Respiratory-- Feet-- Head-- Body--

  • Hands--
  • Eyes--
  • Face--
  • Ears--
  • Respiratory--
  • Feet--
  • Head--
  • Body--

• Likelihood of injury without PPE?

  High -

  Moderate -

  Minimal -

• PPE required to protect the worker

  Select Safety Glasses :: Goggles :: Face Shield :: Ear protection :: Hard hat :: Gloves / Chemical resistant :: Leather cut resistant gloves :: Gloves / Heat Resistant :: Glove / Cryogenic :: Dust Mask "particulate" :: Respirator / half face :: Respirator / full face :: Steel toed boots :: Puncture resistant boots :: Chemical resistant shoes :: Non slip soles :: Back support belt :: Reflective vest :: Tyvek coveralls :: Welding goggles / Helmet :: Heat resistant arm covers ::9 Ear Muffs

  • Safety Glasses ::
  • Goggles ::
  • Face Shield ::
  • Ear protection ::
  • Hard hat ::
  • Gloves / Chemical resistant ::
  • Leather cut resistant gloves ::
  • Gloves / Heat Resistant ::
  • Glove / Cryogenic ::
  • Dust Mask "particulate" ::
  • Respirator / half face ::
  • Respirator / full face ::
  • Steel toed boots ::
  • Puncture resistant boots ::
  • Chemical resistant shoes ::
  • Non slip soles ::
  • Back support belt ::
  • Reflective vest ::
  • Tyvek coveralls ::
  • Welding goggles / Helmet ::
  • Heat resistant arm covers ::9
  • Ear Muffs

• Add media

  Media

• Recommendations on PPE application

• Are other controls required to minimize hazards

  Yes

  No

  N/A

• Recommended additional controls to reduce hazard

• Add media

  Media

Approval

• JSA's approved Manager/Supervisor signature

  Sign

• Print name

• Date approved

  Date

• Would you like to add a comment?

• Comment