Job Hazard Analysis Form EmailThis field is for validation purposes and should be left unchanged.Rival Services - Job Hazard Analysis (JHA)Number: 9.2.1 Section: Safe Practices Date of Issue: 07/01/2015 Date of Revision:Nearest Emergency Contact:Emergency Phone #:Muster Point:Site Coordinates:Nearest Intersection:Wind Direction:Project Supervisor:DESCRIPTION OF WORKList and discuss the Major Job Steps, the Potential Hazards of each step and associated Consequences, and actions to eliminate or reduce hazards, and revise as conditions change during the course of the day’s activities.Project Description:Major Job StepsPotential Hazards & ConsequencesActions Taken to Eliminate HazardIdentification of Potential Hazards/Safe Work PracticesLocation/Site:Date MM slash DD slash YYYY Potential Hazards: (Check all that apply): Environmental Extremes (Inclement Weather) Lifting Hazards Fall Potential Electrical Shock Overhead Powerlines Skin Irritants Confined Spaces Elevated Load or Work Short Service Employees High Pressure Equipment Trapped Pressure (Ice Plugs) Water/Drowning Hazard Fire or Explosion Potential High Noise Levels Excavation Hazard Body Position/Ergonomic Pinch, Crush, or Striking Hazards Hazardous Chemical Exposure (e.g. H2S) Sharp Edges or Hot/Cold Surfaces Other Other potential hazards:OneCall#:Required PPE for Job Task: Hard Hat Safety Glasses Steel Toed Boots Hearing Protection Face Shield Goggles Lifeline/Body Harness Air Purifying Respirator Supplied Air Gloves Other Other Required PPE:Potential Environmental Impacts: Equipment or Operation Noise Release of Gas/Liquid/Solid Dust Storm water/Sediment Pollution River/Stream/Wetland Construction Temperature Extremes Wildfire Other Other potential environmental impacts:Applicable Safe Work Practices: Confined Space Entry Permit Hot Work Permit Energized Electrical Work Permit Special Pre Job Safety Discussions Simultaneous Operations (SimOps) Use of Specialized PPE (Chemical Glove, Apron for Fueling, Personal H2S Monitor) Permit #s:1. Have all workers received orientation? Yes No 2. Does everyone involved in the work understand the job hazards, processes, and safe work practices (such as MSDS, proper tools and equipment, opening process equipment and piping, safety manual rules for equipment, and permitting requirements) associated with the work? Yes No 3. Are all applicable permits in place (hot work, confined space, lockout/tagout)? Yes No 4. Are all workers trained in the specific job tasks? Yes No 5. Does everyone understand the job’s emergency evacuation plan? Yes No If you have answered No to Any questions contact your supervisor to proceed.Name of Person Completing the Form:(Required)Email(Required) SignatureDate(Required) MM slash DD slash YYYY JHA Awareness Sign-In SheetNameCompanyNameCompanyNameCompanyNameCompanyNameCompanyNameCompanyNameCompanyNameCompanyNameCompanyNameCompanyCAPTCHA
