Request Job Hazard Analysis / JHA

1. Conduct an initial job review analysis identifying hazards and hazard control methods 2. Complete the form below 3. A JHA first draft will be completed and e-mailed to you for your review and approval

Name *

First

Last

Company Name *

Email *

Phone Number *

Requested Due Date *

JHA Title *

Scope / Description of Work *

(exp. Painting 5 story building, Concrete Drilling, Installing conduit at elevation, etc.)*

Provide basic task steps including tool and equipment to be used. *

Why is this important? This is needed to identify the dangers of specific steps within a task reducing the risk of injury to workers. The JHA developer will analyze the provided steps identifying potential hazards and hazard control measures, additional steps may also be added. The more information provided the stronger the JHA. If available attach procedures, project requirements, etc., identifying applicable task sections in the documents to be uploaded.

Project required training if applicable

What concerns or hazards have been identified? *

Will you be working with any products that require a Safety Data Sheet? *

What will products with Safety Data Sheets be used for? *

Upload applicable Safety Data Sheets. Safety Data Sheets are needed to identify applicable PPE etc. for products used.

Work in close proximity to powerlines: *

What is the voltage? Select Voltage (nominal, kV, alternating current) *

The value that follows "to" is up to and includes that value. For example, over 50 to 200 means up to and including 200kV.

How was voltage determined or who provided voltage information? *

What is the distance from the work to the powerlines? *

You indicated there is work in close proximity to powerlines. Has the power company or electrical system operator been notified and approved one of the following: • De-energized the lines • Relocated the lines • Or installed protective coverings • Additional OSHA approval? *

Please upload approval documentation at the end of the form.

Will you be working on, over or in close proximity to water? *

How will you be transported to your work location: *

What type of mobile equipment will be used: *

Please enter none or n/a if not applicable.

Will you be working above 6’? *

What tasks will be performed above 6’ and with what type of manlift(s) and/or ladders(s)? *

What and where are your tie-off points: *

In the event of a fall how will the fallen worker will be rescued (Ladder, aerial lift, etc.)? *

Will there be hot work? *

What type of Hot Work? *

What type of material, material handling and transport methods will there be: *

Please enter none or n/a if not applicable.

What type of material will be set in place and how: *

Please enter none or n/a if not applicable.

Will scaffolding be used? *

What type of scaffolding will be used: *

Number of Support Documents to Upload

Maximum size of each file is 5 MB.

Note: When uploading procedures identify applicable work verses subcontracted work. If applicable the following types of documents will be needed: Submit applicable Safety Data Sheets, Drawings, Cover Page Photo, etc.

First Support Document