Job Hazard Analysis Form
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1APPENDIX A
Job Hazard Analysis
1. Name of Employer:
Acme State Agency
2. Date JHA was completed:
June 6
3. Title of Job:
Changing a tire
4. Person Assisting with JHA:
Jane Doe
5. Person Completing JHA:
Joe Smith
6. Date JHA was revised:
June 6
7. Location / Dept. /Facility:
Agency parking lot
8. Recommended Personal Protective Equipment (Check Box and List Type):
9.
Head
10.
Hand Gloves
11.
Foot Safety boots
12.
Hearing
13.
Eye Safety glasses
14.
Face
15.
Torso
16.
Leg
17.
Electrical
18.
Respiratory
Other – List:
19.
20. Special Equipment:
Lug wrench and jack
21. Special Precautions:
Set emergency brake
22. Specialized Training
23. Testing/Monitoring
Equipment:
Sequence of Events
Potential Accidents or Hazards
Preventive Measure
24.
25.
26.
Park vehicle
Vehicle rolls forward or backward
Set emergency brake
Get lug wrench, jack and spare
Lifting (motion)
Use proper lifting technique
tire
Loosen lug nuts
Wrench slipping off lug nut/overexertion
Use proper size tool
Raise (jack up) vehicle
Vehicle falls off jack
Proper positioning of jack
Remove tire
Lifting (motion)
To minimize lifting, raise vehicle just high enough to remove tire
Place spare tire on
Lifting (motion)
To minimize lifting, raise vehicle just high enough to place tire on
Lower (jack down) vehicle
Body part caugth under vehicle
Stay clear of underside of vehicle when lowering
Tighten lug nuts
Wrench slipping off lug nut/overexertion
Use proper size tool
Put away lug wrench, jack and
Lifting (motion)
Use proper lifting technique
old tire
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Parent category: Business