Task Hazard Analysis Form Page 2
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2Additional PPE Required:
Protective Clothing
Face shield
Welding Shield
Goggles
PFAS
Was anyone injured today?
Yes
No
If so, was it reported?
Yes
No
Note: Work shall stop when conditions change, the job changes, or deficiency in the plan is discovered, and the current THA will be modified or a new Task Hazard Analysis created. Additional
Permits-checklists are required for equipment, Confine space, trenches, excavations, hot work, line breaks, and Lock out/tag outs. Cranes, CAZ, Scaffolds, etc. See Site Safety if unsure.
PLEASE SIGN THIS DOCUMENT AFTER YOUR SUPERVISOR HAS REVIEWED THE TASK HAZARD ANALYSIS (THA) WITH YOU.
PRINT NAME
CRAFT/TRADE
PRINT NAME
CRAFT/TRADE
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____________________________________________
____________________________________________
Foreman/Supervisor/Superintendent
LeChase Management
____________________________________________
____________________________________________
Subcontractor Supervisor/Leader Person
Subcontractor Management
Printed on recycled paper.
Updated 11.08.2012
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