SEES JHA Form

This document will be completed by the Schneider Electric Engineering Services Lead Engineer (Person in Charge). It will be discussed with the customer, other contractors and all the persons involved in the activity. When completed it will be communicated and signed by all persons involved in the activity before any work starts.

• Please press the arrow above or simply swipe to continue.

• Project Name

• Date and time

  Date
• Site location
  Address

• Site Contact/Number

• Scope of Work

  Select Data Collection Site Walkthrough Grounding Assessment Use of PPE Safety Meeting Field Harmonic Analysis Power Quality Analysis Hydration Plan Tool Management Use of Portable Meters Setting Changes on Relays Setting Changes on Breakers Equipment Commissioning Sales Call Pre-Order Site Visit Presentation ESWP Meeting / Data Mining Troubleshooting pH Soil Test Anaerobic Soil Test AF Mitigation - Site Evaluation Open Energized Equipment Verification of De-energized Equipment Lock Out - Tag Out Switching Work with Others Demo Equipment Install Equipment

  • Data Collection
  • Site Walkthrough
  • Grounding Assessment
  • Use of PPE
  • Safety Meeting
  • Field Harmonic Analysis
  • Power Quality Analysis
  • Hydration Plan
  • Tool Management
  • Use of Portable Meters
  • Setting Changes on Relays
  • Setting Changes on Breakers
  • Equipment Commissioning
  • Sales Call
  • Pre-Order Site Visit
  • Presentation
  • ESWP Meeting / Data Mining
  • Troubleshooting
  • pH Soil Test
  • Anaerobic Soil Test
  • AF Mitigation - Site Evaluation
  • Open Energized Equipment
  • Verification of De-energized Equipment
  • Lock Out - Tag Out
  • Switching
  • Work with Others
  • Demo Equipment
  • Install Equipment

• Additional details of scope of work

• Internal emergency number

• External emergency number

• Fire extinguishers locations

• Details of emergency plan:

• All hazards/ Risks will be detailed here:

  Select Chemical risk Confined space Contractor safety Cranes & hoists Driving Electricity Energy efficiency Ergonomics Fire Health Hot substances Machine safety Material handling Pollution Powered Industrial Trucks Production Slips, trips & falls Travel Waste Water Working at heights Sharp objects Fork Lift

  • Chemical risk
  • Confined space
  • Contractor safety
  • Cranes & hoists
  • Driving
  • Electricity
  • Energy efficiency
  • Ergonomics
  • Fire
  • Health
  • Hot substances
  • Machine safety
  • Material handling
  • Pollution
  • Powered Industrial Trucks
  • Production
  • Slips, trips & falls
  • Travel
  • Waste
  • Water
  • Working at heights
  • Sharp objects
  • Fork Lift

• What control measures were implemented?

• Documentation required to complete scope of work, attach if necessary.

  Select LOTO Confined Space Energized Work Permit Emergency Action Plan other then in JHA Other Additional Local Safety Training Badges Requested Documentation Proof of Insurance

  • LOTO
  • Confined Space
  • Energized Work Permit
  • Emergency Action Plan other then in JHA
  • Other
  • Additional Local Safety Training
  • Badges
  • Requested Documentation
  • Proof of Insurance

• Arc flash data collection for exposed energized equipment hazards. Note that opening equipment with the sole purpose of obtaining conductor information is no longer an acceptable practice and it violates SE safety policies.

• Arc Flash Risk Assessment (AFRA)? AFRA shall be completed to determine the appropriate safety-related work practices, the arc flash boundary and the proper PPE.

  Yes

  No

  N/A

• Limited Approach Boundaries? 50V - 750V set cones and barriers to 3'6" unless

• IMPORTANT! If the hazard cannot be controlled DO NOT PROCEED.

• All Persons involved in the activity must sign this document to verify that the contents are fully discussed, agreed and understood by all.
  

• Singee I

  Sign

• Signee II

  Sign

• Signee III

  Sign

• Signee IV

  Sign

• Signee V

  Sign

• Signee VI

  Sign

• Signee VII

  Sign

• Signee VIII

  Sign

• Signee IX

  Sign

• Signee X

  Sign