OPRD JOB HAZARD ASSESSMENT FORM (rev.10.

11)
JOB: JOB LOCATION:

IDENTIFY HAZARDS: Please check all hazards that apply for this job or project. 1. 2. 3. 4. 5. 6. 7. 8. 9. Aerial lifts Animals/insects Bloodborne pathogens Chemical exposure Cold/wet conditions Confined spaces Dust/flying particles Electric shock Ergonomic hazards 28. OTHER, SPECIFY: 10. 11. 12. 13. 14. 15. 16. 17. 18. Excavation cave-in Excessive heat Falls from height Fire/explosion Hand/powered tools 19. 20. 21. 22. 23. Noise Overhead hazards/falling objects Poisonous plants Radiation Scaffolding Slip/trip/fall Vehicle traffic Unguarded machinery Welding equip./compressed gases

Hazardous atmospheres 24. Heavy equipment High vibration Low visibility 25. 26. 27.

IDENTIFY HAZARD CONTROLS For each hazard checked above, list the corresponding hazard number and explain how employees will be protected from injury: engineering or work practice controls, personal protective equipment (PPE). Hazard No. Hazard No. Hazard No. Hazard No. Hazard No. Hazard No. Hazard No. Hazard No. Hazard No. Hazard No. ControlControlControlControlControlControlControlControlControlControl(ATTACH ADDITIONAL PAGES IF NEEDED)

Safe Operation Procedure (SOP) and PPE required for job:

(ATTACH ADDITIONAL PAGES IF NEEDED) SIGNATURES & CERTIFICATION: All employees on this job or project will be informed of these hazards/controls. Person Conducting JHA: Managers Signature: Date: Date:
As of 10.2011