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JOB HAZARD ASSESSMENT (JHA)

Workplace/Project Name: *

JHA Predecessor: *

Contact Person: *

Phone No: *

JHA No: (If applicable): *

JHA Successor: *

Work Activity / Job / Task Or Process Description: *

Name Of Employees Involved In Initial JHA Development(Print Name): *

Date JHA Developed: *

Nominated Supervisor Of Works(Print Name): *

Authorizing Person(Print Name): *

Signature: *

Clear signature

Date Of Authorization: *

PRE-REQUISITES

Personnel Details

Equipment/ Site Details

Qualifications (Licenses/Qualifications): *

Mobile Plant/ Static Plant and Equipment: *

Training/Certification required: *

Safety/Emergency Equipment: *

Hazardous Chemical Used During Task, List If Applicable:

Hazardous Chemical SDS attached to JHA

Training To Work(tick if applicable)

Product Name

Yes No

Confined Space Entry

Working at Height

Excavation

Lock Out/Tag Out

Hot Work

Inspection Plan

Work Sequence Basic Job Steps

Risk & Hazard/ Issue Description

Controls

Controlled Risk Level

Who Will Do This?

Break the job down into steps.Each step should accomplish some major task and be in a logical sequence

There is a risk that :
because :

- No. of people to do the task
- Occupations of people req’d
- Licenses, Qual’s, Permits
- Training requirements
- Approvals, Plans & Permits
- Engineering Drawing/Ref’s
- Environmental controls

- Lift Studies / Calculations
- Plant & Equipment (static or mobile)
- Safety Equipment
- PPE
- SDS

STOP

CHECK

START

Wherever possible list who specifically (by name) and when this needs to be done.

List all PPE which is standard and mandatory for this task:

Assess employee’s fitness for work

• Fatigue
• Impaired worker/s under the influence of drugs or alcohol

• Employee’s to adhere to Company’s Fatigue Management Plan
• Employees to comply with Company Drug and Alcohol Policy

START

Site Superintendent,
General Foreman,
Carpenter Foreman,
Employees

START

Names OF People Involved In Developing The JHA And Consultation Indication:

Employee Name	Signature(I have been consulted in and understand this JHA)	Date
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	Clear signature
	Clear signature
	Clear signature
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Review No	01	02	03	04	06	07
Initial:
Date:

Audit No	01	02	03	04	06	07
Initial:
Date:

JHA AMENDMENT REASON/DETAILS	CHANGE MANAGEMENT ACTIONS (e.g., actions taken to communicate changes)	Date
JHA Created	Crew to sign on to JHA
	Clear signature
	Clear signature
	Clear signature

Employee Name	Signature((I have been consulted in this JHA))	Date
	Clear signature
	Clear signature
	Clear signature
	Clear signature
	Clear signature