Job Hazard Analysis Form

Revision No. 1
Job Hazard Analysis: Date:
What is the task: Location:
Apa tugasnya : Lokasi :
Permit Type: ☐Electrical Work ☐Hot Work ☐Confined Spaces ☐ Excavation ☐ Working at Height (specify)
Permit Required: ☐Yes ☐No
☐ Others: _______________ _________________________________
Permit Approved: ☐Yes ☐No Permit Approved By:
Name of JHA Team Contact: Signature:
JHA Team sign on:
Name: Signature: Name: Signature: Name: Signature:

Name of JHA Checker: Signature:

Personal Protective Equipment (PPE) Required (Check the box for required PPE):

Face/Dust Hearing Appropriate Appropriate

Hard Hat Face Shield Eye Protection Overalls Hi –Vis Weld Mask
Masks Protection Footwear Gloves
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Oxy-Acetylene
Sunscreen Goggles
Harness Long-sleeves Respirator Others Others Others Others Others
Lotion

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
STEP TASK STEP HAZARD IMPACT CONTROLS
What am I doing what can hurt me / others or impact on the What harm could occur What must be in place to prevent harm ? (include
environtment specific responsibilities where applicable)
Langkah tugas apa yang Dampak apa yang dapat
akan saya lakukan Bahaya apa yang bisa melukai saya/orang menyebabkan kerugian Kontrol apa yang harus ada untuk mencegah
lain/berdampak pada lingkungan bahaya ? (Sertakan tanggung jawab spesifikasi jika
berlaku)
Change Management and Approval
Date & Time Step # Description of Change New Controls Change Approved
Sign On and Change Acknowledgement Register
Date Time Name Signature Date Time Name Signature