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Document Title: JOB HAZARD ANALYSIS (JHA) FORM

Document Type: Level 3 Issue Date: Revision: 0

Job Task: Performed By: Date:

Business Unit: Reviewed By: Date:

Location: Approved By: Date:

Personal Protective Equipment (PPE)

Head Hard Hat Bump Cap Other, Specify:

Eye/Face/Neck Safety Glasses with Side Shields Goggles Face Shield Other, Specify:

Respiratory [1] Filtering Facepiece (Dust Mask) Half-Face Respirator Full-Face Respirator Other, Specify:

Ears Ear Plugs Earmuffs Double Protection Other, Specify:

Cotton Puncture/Cut-Resistant Chemical-Resistant Other, Specify:

Hands/Arms Leather Thermal-Resistant Specify Type Below:
Anti-Vibration Arm Sleeve Neoprene

Feet Steel/Composite Toe Chemical-Resistant Traction Aid Other, Specify:

Company-Supplied Uniform Apron – Chemical Knee pads, optional, Other, Specify: Safety Harness
Body Tyvek (or similar) Suit Apron – Leather as necessary
High Visibility Clothing Apron - Cloth

[1]
Respiratory protection is only required when inhalation exposures exceed permissible limits, which will be determined at the local level. Voluntary use of filtering facepieces (dust masks) may be
allowed provided certain conditions are met.

Hazards and Precautions

Lifting Hazards Chemical Exposure High Noise Levels Other, Specify:
Fall Potential Skin Irritants Ionizing Radiation Walking Surfaces
Potential Electrical Shock Confined Spaces Sharp Edges
Hazards Elevated Load or Work Fire or Explosion Hot/Cold Surfaces
Potential Release of Energy Excavation Hazard Pinch, Crush, or Striking Hazards
Water/Drowning Hazard Environmental Extremes

Hot Work Permit Special Pre-Job Safety Discussions Energy Isolation Procedures Other, Specify:
Safe Work Site / Job Orientation Confined Space Entry Review of Emergency Action Plans
Practices Use of Barricades Use of Specialized PPE

Special Pollution Prevention Measures Redundant Protection Measures Simultaneous Operations Other, Specify:
Precautions
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Document Title: JOB HAZARD ANALYSIS (JHA) FORM

Document Type: Level 3 Issue Date: Revision: 0

Sequence of Basic Steps Potential Hazards Recommended Action or Procedure

Pre-Operation Inspection

Operation

Post-Operation