Job Hazard Analysis (Jha) Page 3
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3FIELD LEVEL HAZARD ASSESSMENT
Date/Time:
Assessment Location(s):
Job #:
Operation (i.e. paving, trucking, plant setup/teardown, etc.):
Permit Required: Yes___ No___
Identify the tasks and hazards below. Explain the plan(s) to eliminate/control the hazards.
Item #
Task
Hazards
Plan to Eliminate/Control
Is the worker working alone?
If Yes. Explain?
Yes ____ No ____
There any Hazards remaining? Yes___ No___ (If Yes, explain)
Workers Name(s)
Foreman Name: ___________________
add the names of all people involved in the JHA
_______________________ ___________________ ____________________ __________________
_______________________ ___________________ ____________________ __________________
_______________________ ___________________ ____________________ __________________
_______________________ ___________________ ___________________
__________________
Reviewed by: __________________
(All names must be legible)
WORKPLACE HAZARD ASSESSMENT CORRECTIVE ACTION
Assessment Location(s):
Date/Time:
Operation (i.e. paving, trucking, plant setup/teardown, etc.):
Job #:
Action Taken
Item #
Recommended Action Taken
By Whom
Date/Time
Foreman/Superintendent Signature:
Date:
Reviewed by:
Date:
Assessment Team: ___________________
______________________ ______________________
___________________
______________________ ______________________
(add the names of
___________________
______________________ ______________________
all people involved
___________________
______________________ ______________________
in this JHA
___________________
______________________ ______________________
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Parent category: Business