﻿Job Safety Analysis
 




JOB INFORMATION


Date:*(MM/DD/YYYY)


 
Start Time:*


End Time:*


Client:*


Client Contact:*


Client Contact Number:*
### ### ###                     Co. Competent Person:*
First Name, Last Name
Job Name:*


Job Site Address:*
Street line 1:
Street line 2:
City
 
State/Province
 
Zipcode
Landmarks or Intersections:*


Speed Limit:*
 
Type Of Roadway*
 One Way Road
 Two Way Road
 Three way Intersection
 Four Way Intersection
 Multilane Highway
 Limited Access Highway
 Paved Unpainted Road
 Gravel Road
 Dirt Road
 Private Road
Others. Please explain


Traffic Volume:*
 Light
 Medium
 Heavy
Obstructions:*


Weather Conditions:*
 Light Rain
 Heavy Rain
 Foggy
 Windy
 Clear Sky
 Partly Cloudy
 Overcast
 Thunder/Lightning
 Snow
 Ice
 Smog
Others. Please explain


Shoulder Conditions:*
 No Shoulder
 Narrow Shoulder
 Adequate Shoulder
 Guardrail
 Debris on Shoulder
 Sharp Drop Off
 Others. Please explain


EMERGENCY PROCEDURES


Designated Co. Competent Person:*
First Name, Last Name
Are 911 systems functional with cell phone use?*


Local Medical Clinic:*


Medical Clinic Contact Number:*
### ### ####
Is First Aid Kit on site and fully stocked? 


 Is Fire extinguisher on site, fully charged, and appropriate for potential fire types?
 
JOB/TASK FOR THE DAY


Check Type Of Work Being Performed:*
 Flagging
 Flagging With Rumble Strips
 Flagging With TMA
 Shoulder Closure
 Lane Closure
 Slow Roll
 Shop Work
Others. Please explain


Stationary or Mobile:*
 Stationary
 Mobile
 
Others. Please explain
Sidewalk Redirection:*
 Yes
 No
JOBSITE EXPOSURES


Hazard Identification: Number each hazard. Describe the mitigation in the Hazard Controls Measures section below. Items in this section relate to existing conditions or may be a result of site operations.




Physical Hazards:*
 Backing Equipment
 Electrical
 Falls from Elevation (Truck Bed)
 Moving Equipment
 Traffic Volume
Others. Please explain
Health Hazards*
 Biological (Animal, Avian, Insect)
 Chemical Exposure
 Cold Stress
 Heat Stress (CA __ > 80° __ > 95°)
 High Noise (> 85 dB)
 Lifting Over 50 lbs.
Others. Please explain
Environmental Hazards*
 Elevation / Site Terrain
 Fire Hazards/ Hot work
 Nighttime Work/ Visibility
 Road Surface/ Grade/ Visibility
 Silica/ Dust
 Weather
Others. Please explain
HAZARD CONTROL MEASURES


Daily Toolbox Talk Subject:*


Inspections Performed:*
 Arrow board(s)
 Equipment
 Housekeeping
 Load Securement
 Cones/Barrels
 Message Board(s)
 Rumble strips
 Radios (Charged)
 Signs (Legible, Reflectivity)
 Stands
 Tools (Grounded/Guards)
 Truck(s)
 TMA(s)
 your choice here.
Others. Please explain
PPE Required:*
 Class 3 Vest
 Class E Pants
 Gators
 Whistle
 Gloves
 Hard Hat
 Halo Hard Hat Light
 Safety Glasses
 Ear Muffs (> 110 dB)
 Ear Plugs (> 85 dB)
 Respiratory
 Safety Goggles
 Shade (Flagger Joe)
 Face Shield
 Fall Protection
 Safety Toe Boots
Others. Please explain
ADDITIONAL COMMENTS




By signing below, I hereby acknowledge that I have attended the Job Hazard Assessment (JHA) meeting referenced on this document. Furthermore, I am stating the information presented was discussed and explained to my understanding. If for ANY reason there is an issue that arises during this task, I confirm my responsibility of using- Stop Work Authority to ensure all safety hazards and concerns are addressed completely.*


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