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Blank JHA Form (Check Box Form)

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44 views2 pages

Blank JHA Form (Check Box Form)

Uploaded by

braulio.correa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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COMPANY NAME: PAGE 1 OF 2

TIME:

PROJECT NAME & NUMBER:

JOB BRIEFING / ROUTINE JOB HAZARD ANALYSIS (JHA) FORM


Complete with work crew at job-briefing before beginning work; Have all affected personnel sign-off in Block 9 of this form.
(1) JOB INFORMATION

Date: Job Name: Job Number:


Physical Address: Longitude: Latitude: Supervisor/Crew Lead:
(2) EMERGENCY PROCEDURES (LIST TELEPHONE NUMBERS AND ATTACH DIRECTIONS TO THE SITE.)
Are 911 systems functional with cell phone use? Yes No
Fall Protection Rescue Procedures to Fire Department In-House Crew (Crew must be properly trained in rescue) Other: Please describe.
be used:
Ambulance: Fire: Police:
Local Hospital: Telephone Co: Utility Co:
Evacuation Point: Superintendent & Cell Phone: Safety & Cell Phone:
(3) JOB / TASKS FOR TODAY (Note: Any rigging with a payload weight of 10T - 50T = Medium Lift; or > 50T= Heavy Lift; or a Critical Lift requires the
submittal of an Engineer approved lift plan as required per contract requirements.)
CHECK TYPE OF WORK BEING PERFORMED:
Working at Height > 6 feet Electrical Construction Civil/Concrete/Masonry Scaffolding
Heavy Lift (>50T), Incidental Lift (<10T) Welding Heavy Equipment Decommissioning Other:
(4) JOBSITE EXPOSURES, NOTE: ELECTROMAGNETIC INTERFERENCE (EMI), RADIO FREQUENCY (RF)

Hazard Identification: Items checked below relate to existing conditions or may be a result of site operations
Physical Hazards Health Hazards
Confined Space Permit Required Struck by/Contact With Chemical Exposure Silica Exposure (Concrete/Stone
Electrical Overhead Work Cold Stress Cutting)
Elevation / Site Terrain Slips, Trip, or Falls EMI/RF/Radiological/Laser Biological Hazards: Animals, Avian,
Falls from Elevations Underground Utilities Heat Stress Insects, Microbiological, etc.
Fire Hazards Vehicle Traffic High Noise (>85 dBA) Asbestos, Lead
Heavy Equipment Other: Lifting Hazards Other:

(5) HAZARD CONTROL MEASURES

PPE and Monitoring Equipment Inspections Safety Systems / Training


(Complete All Prior to Use)
Fall Protection Tools/Equipment Barricades, Pedestrian Shelters, Banner of Notices, PPE, and Warning Signs)
Gloves Rigging Excavation & Trenching Plan/Log
Hard Hat Housekeeping Lock-Out / Tag-Out
Hearing Tag Lines Job Briefing Meeting
Respirators Ground Fault Protection Pre-Approved Plans (Critical Lifts, Roped-Access, Suspended Personnel Lift)
Hazmat Suits; Level: D, C, B, A Cranes Color Coded Inspection Schemes for Rigging, Equip., Electrical Cords &
Safety Glasses, Goggles, Face Shield Hoists Tools; Annotate Colors, Items, & Frequency.
Safety Vest: Class 1, 2, 3 Other: Uniform Traffic Control
Air Monitoring: Permit Systems:
Oxygen Deficiency (< than 19.5%) Confined Spaces: Is a Permit Required? o Yes Obtained o
Oxygen Enrichment (> than 23.5%) Electrical Work: Is a Permit, Outage, or Clearance Required?o Yes Obtained o
Flammable Gases/Vapors (> than 10% of LEL) Fire, Smoke, Heat Alarms Deactivation: Are Permits Required? o Yes Obtained o
Airborne Combustible Dust (> than LFL) Welding/Hot/Burning: Is a Permit Required? oYes Obtained o
Toxic Gases or Vapors (> than PEL)
Pressure/Chemical Pipe Opening: Is a Permit Required? o Yes Obtained o
Noise Monitoring:
Egress Evacuation Routes Altered: Is a Permit Required? o Yes Obtained o
Laser Safety:
Other:
Other:
NOTE: Notify and confirm proper procedures, mitigation and/or protective steps taken with the designated Safety Representative before entering: any trench or any
general excavation that is greater than 5’ deep; or any Confined Space.
(6) COMPLETE FOR CIVIL WORK (PLEASE NOTE: ENGINEER APPROVED TRENCHING PLAN REQUIRED FOR TRENCHES > 5’)

1. Describe type and depth of excavations Type A Soil/Rock Type B Soil/Rock Type C Soil/Rock:

REV: 0, 03/26/09
COMPANY NAME: PAGE 2 OF 2

TIME:

PROJECT NAME & NUMBER:

JOB BRIEFING / ROUTINE JOB HAZARD ANALYSIS (JHA) FORM


2. Cave-in / Engulfment control measures to be used if excavation will be greater than 5 feet and personnel are entering the trench. Sloping Benching
Shoring Trench Shield/Box Ladder in Trench > 5 Feet & Every 25’ Sump Pump LOTO:
3. Describe elevation/site terrain/environmental concerns or hazards:

4. Describe hazards with site/vehicle access (High Traffic, Heavy Haul, Boom Cranes, and storage of materials/HazMat:

5. Describe the type of electrical or gas concerns or hazards (e.g. Electrical/Gas/Fiber Optic Lines):

(7) FALL PROTECTION & USING SUSPENDED PERSONNEL PLATFORM (Complete for Working at heights and Roped-Access)

Type of Elevated Work & Height: Type of Tower or Building:

Describe the fall protection system to be used when working aloft. Lifeline Personal Fall Arrest Safety Monitor Qualified Climber Safety Net
Ladder Safety Device Roped Access (Requires Roped Access JHA):
Fall protection to be used. Full Body Harness One Lanyard Two Lanyards (100%) Rope Grab Cable Grab Retractable Lifeline Ropes
Ascenders/Descenders Anchorage Points, Belay, & Straps:
Has each employee inspected his or her fall protection equipment? Yes No
Hoisting Equipment to be used: < 20’ Encroachment of Power Lines, Yes No; If yes, ID Voltage _______KV; De-energize/Test/Ground Lines Yes No
Suspended Personnel Platform/basket Forklift Platform Crane/Boom/Aerial Truck Scissor/Snorkel Lift Gin Pole Roped Access
Suspended Personnel Platform Checklist and/or Critical Lift Plan Completed? Yes No
(8) REVIEWS AND SIGNATURES

GC Superintendent /Foreman Lower-tier Subcontractor Supervisor


Name Signature Name Signature

(9) PROJECT PERSONNEL ACKNOWLEDGEMENT (ALL AFFECTED PERSONNEL SIGN AFTER JOB BRIEFING)

Name: Company: CPR / First Aid Name: Company:


Yes Yes

Yes Yes

Yes Yes

Yes Yes

Yes Yes

Yes Yes

Yes Yes

REV: 0, 03/26/09

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