Task Hazard Analysis Form

• Project Name

  Select
• Project Location
  Address

• Date Conducted on

  Date

• Prepared by

• Subcontractor

• Task to be performed

• Number of employees for this task

• DDS Division

  Select

Task Description

• Check all that apply.

  Select Working at Height >6ft Boring Trenching/Excavation Utility Marking Electrical General Construction Heavy Equipment Demolition Other

  • Working at Height >6ft
  • Boring
  • Trenching/Excavation
  • Utility Marking
  • Electrical
  • General Construction
  • Heavy Equipment
  • Demolition
  • Other

Jobsite Exposures

• Check any existing conditions or what may result from site work.

• Check all Physical Hazards that apply.

  Select Electrical Confined Space Falls from Elevations Fire Hazards Heavy Equipment Struck by/Caught in-between Overhead Work Underground Utilities Slips, Trips, or Falls Vehicle Traffic Required Permit(s) High Winds Animals Others

  • Electrical
  • Confined Space
  • Falls from Elevations
  • Fire Hazards
  • Heavy Equipment
  • Struck by/Caught in-between
  • Overhead Work
  • Underground Utilities
  • Slips, Trips, or Falls
  • Vehicle Traffic
  • Required Permit(s)
  • High Winds
  • Animals
  • Others

• Please list all other physical hazards that apply.

• Check all Health Hazards that apply.

  Select Cold/Heat Strees Chemical Exposure High Noise > 85 dBA Lifting Hazards Biological Hazards Asbestos, Lead, or PCBs Other

  • Cold/Heat Strees
  • Chemical Exposure
  • High Noise > 85 dBA
  • Lifting Hazards
  • Biological Hazards
  • Asbestos, Lead, or PCBs
  • Other

• Please list all other health hazards that apply.

HAZARD CONTROL MEASURES

• PPE and Monitoring

  Select Fall Protection Gloves Hard Hat Safety Boots Hearing Protection Safety Glasses Safety Vest (DOT Approved) Air Monitoring Laser Safety Other

  • Fall Protection
  • Gloves
  • Hard Hat
  • Safety Boots
  • Hearing Protection
  • Safety Glasses
  • Safety Vest (DOT Approved)
  • Air Monitoring
  • Laser Safety
  • Other

• Please list other PPE and monitoring.

• Inspections

  Select Tools/Equipment Ladders Rigging Housekeeping Tag Lines GFCI Hoist, Slings, Chains Tree Trimming Other

  • Tools/Equipment
  • Ladders
  • Rigging
  • Housekeeping
  • Tag Lines
  • GFCI
  • Hoist, Slings, Chains
  • Tree Trimming
  • Other

• Please list other inspections.

• Safety Systems/Training

  Select Barricades, Notices, Warnings Excavation Plan (Call 811) LOTO Job Briefing Meeting Traffic Control* Confined Space Permit ElectricalWork Permit Hot Work Permit Asbestos/Lead/PCB Tested Other

  • Barricades, Notices, Warnings
  • Excavation Plan (Call 811)
  • LOTO
  • Job Briefing Meeting
  • Traffic Control*
  • Confined Space Permit
  • ElectricalWork Permit
  • Hot Work Permit
  • Asbestos/Lead/PCB Tested
  • Other

• Please list other safety systems/training

• *A traffic plan must be attached to the THA when there is a potential for interface with traffic flow.

  

Specific Task Steps

• NOTE: EACH TASK REQUIRES A SEPERATE TASK HAZARD ANALYSIS
  If a deficiency in the plan is discovered, or if the task/condition changes, work shall stop and the current THA will be modified or a new one created. Additional Permits/Checklists are required for equipment, confined space, trenches, excavations, hot work, line breaks, lock-out/tag-out, cranes, CAZ, scaffolds, pressure test, etc. See your supervisor if unsure.

• List Steps to be performed

• Hazard associated with each step.

• Required actions to eliminated or control hazard.

Signatures/Approvals

• I confirm by my name below, that I have attended a briefing on the requirements of the attached THA and agree to perform the work in the manner detailed on it.
  I confirm that copies of the relevant Permits, SDS’s, Isolation Plans, etc. have been reviewed.

• Print Name

• Craft/Trade

• Print Name

• Craft/Trade

• Print Name

• Craft/Trade

• Print Name

• undefined

• Foreman/Supervisor/Superintendent (Print Name)

• Signature

  Sign

• LeChase Management (Print Name)

• Signature

  Sign

To be completed at end of shift

• Was anyone injured today?

  Yes

  No

  N/A

• Was it reported?

  Yes

  No

  N/A