SSB-JOB HAZARD ANALYSIS

• JOB #

• JOB ADDRESS
  Address

• CURRENT DATE AND TIME

  Date

• EMPLOYEE COMPLETING FORM ENTER NAME HERE (ULTIMATE AUTHORITY/SUPERVISOR)

• WILL CUSTOMER OR PROPERTY OWNER EXPERIENCE ANY OUTAGES?

  Yes

  No

  N/A

• IF YES, SLIDE TO LENGTH OF OUTAGE (MINUTES)

HAZARDS

• CHECK ANY HAZARD THAT APPLIES TO THE CURRENT JOB. ALL HAZARDS SELECTED MUST BE DISCUSSED AS A GROUP.

• ELECTROCUTION HAZARD

• CONFINED SPACE HAZARD

• ELEVATION HAZARD

• UNSAFE TERRAIN HAZARD

• SLIP/TRIP/FALL HAZARD

• FIRE HAZARD

• VEHICLE TRAFFIC HAZAD

• HEAVY EQUIPMENT OPERATION HAZARD

• EXPLOSION HAZARD

• OVERHEAD UTILITY HAZARD

• UNDERGROUND UTILITY HAZARD

• HOT WEATHER HAZARD

• COLD WEATHER HAZARD

• INCLEMENT WEATHER HAZARD

• CHEMICAL EXPOSURE HAZARD

• LIFTING HAZARD

• ASBESTOS HAZARD

• SILICA HAZARD

• EXCESSIVE NOISE VOLUME HAZARD

• HEAD INJURY HAZARD

• HAND INJURY HAZARD

• FOOT INJURY HAZARD

• LOW VISIBILITY HAZARD

• POOR HOUSEKEEPING HAZARD

• VIBRATION HAZARD

• PINCH POINT HAZARD

• AIR CONTAMINATION HAZARD

• EXCAVATION HAZARD

• ADD PHOTOS OF ANY SPECIFIC OR UNUSUAL HAZARDS YOU WISH TO REPORT

  Media

PERSONAL PROTECTIVE EQUIPMENT

• CHECK ALL PERSONAL PROTECTIVE EQUIPMENT THAT WILL BE USED

• HARD HAT

• REFLECTIVE HARD HAT COVER

• SAFETY GLASSES/SIDE SHIELDS

• FALL PROTECTION

• GLOVES

• HEARING PROTECTION

• RESPIRATOR/DUST MASK

• REFLECTIVE VEST

• FOOT PROTECTION

• HAS ALL PERSONAL PROTECTIVE EQUIPMENT TO BE USED BEEN INSPECTED BEFORE USE?

  Yes

  No

  N/A

UNDERGROUND/CONFINED SPACE REVIEW

• WILL EXCAVATIONS BE CONDUCTED?

  YES

  N/A

• ENTER TYPE OF EXCAVATION TO BE CONDUCTED

• SLIDE TO DEPTH OF PLANNED EXCAVATIONS

• HAVE ALL UTILITIES BEEN LOCATED?

  Yes

  No

  N/A

• HAVE ALL EASEMENTS BEEN CHECKED AND REVIEWED?

  Yes

  No

  N/A

• ARE THERE ANY TERRAIN OR ENVIRONMENTAL CONCERNS?

  YES

  N/A

• IF YES, PLEASE BRIEFLY EXPLAIN.

• ARE THERE ANY VEHICLE ACCESS CONCERNS?

  NO CONCERNS

  CONCERNS

• IF YES, PLEASE BRIEFLY EXPLAIN.

• ARE THERE ANY SPECIAL CONSIDERATIONS (SPOTTER, DIGGING, POTHOLING, ETC.)?

  YES

  N/A

• IF YES, PLEASE BRIEFLY EXPLAIN.

AERIAL AND POLE REVIEW

• WILL AERIAL OR POLE WORK BE CONDUCTED?

  YES

  N/A

• DESCRIBE TYPE OF STRUCTURE (POLE, TOWER, WALL, ETC.)

• DESCRIBE FALL PROTECTION TO BE USED

PERSONNEL INVOLVED

• EACH EMPLOYEE MUST ENTER NAME AND ELECTRONICALLY SIGN

• PERSON COMPLETING FORM

  Sign

• EMPLOYEE #2

  Sign

• EMPLOYEE #3

  Sign

• EMPLOYEE #4

  Sign

• EMPLOYEE #5

  Sign

• EMPLOYEE #6

  Sign

• EMPLOYEE #7

  Sign

• EMPLOYEE #8

  Sign