Serial Number

Job Hazard Analysis

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Section 1 – Work Information

Contract Owner: Facility/Equipment Description:
Contract/Work Order/Job Ticket #: Facility/Equipment Number:
Reference PTW Serial Number: Work to be done (Detailed work description; attach separate page if necessary):
Job Location & Work Boundaries (indicate specific work site and physical limits):

Section 2 – Job Hazard Analysis (attach additional pages when required)

Sequence of Job Steps Tools & Equipment Used For Job Step Potential Hazards Identified Recommended Control Measures

Serial Number
 Job Hazard Analysis
Section 3 – Tool for Identifying the Primary Sources of Potential Job Hazards
Hazard Analysis Consideration General Hazard Specific Hazards Pertinent to
Category Category
Can worker be struck by anything? Struck by (SB) Moving objects
Flying objects
Falling material
Can worker strike against anything? Strike against (SA) Stationary or moving objects
Protruding objects
Sharp or jagged edges
Can worker be caught between Caught between (CB) Moving and/or stationary objects
anything? Pinch points
Can worker come into contact with Contact with (CW) Electricity
any energy source or hazardous Chemicals
material? Hazardous plants
Extreme Heat/Cold
Can worker by contacted by any Contacted by (CBy) Splashing chemicals
energy source or hazardous Animals and Insects
material? Arcing electricity
Can worker be caught on anything? Caught on (CO) Moving parts
Sharp or jagged edges
Protruding objects
Can worker be caught in anything? Caught in (CI) Settling material
Falling material
Moving parts
Can worker fall to same level? Fall, same level (FS) Slip/trip/fall
Poor footing
Wet surfaces
Can worker fall to level below? Fall to below (FB) Unstable footing
Unprotected platforms
Is there a possibility of overexertion? Overexertion (O) Lifting
Pulling / Pushing
Repetitive motion
Is there a possibility of exposure to Exposure (E) Chemical vapors; toxic gases
hazardous chemicals or Oxygen Deficiency
temperatures or other
environmental conditions?
Excessive noise
Radiation
Heat/Cold
Weather conditions
Is there a potential to spill, leak, or Release to (RT) Environmental issues
discharge hazardous materials? Ground/Water contamination
Public involvement
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Section 4 – Categories for Control Measures
Category Example
Elimination or Substitution Use of lead free, non-toxic paint
Use a trolley instead of manual handling
Engineering controls Ventilation
Barricades
Administrative controls No Smoking Policy
Rotating personnel
Job frequency reduction
Safe work practice or procedure Confined Space Entry Procedure
Lock Out/Tag Out Procedure
Gas Testing Procedure
Personal protective equipment Hard hats; safety shoes; safety glasses
Respirators
Chemical Protective Clothing
Fall protection harness
Section 5 – JHA Development Team
Print Name Signature Date Time
Section 6 – Stop Work Instructions
1. Permit Receiver shall return this JHA together with the Safe Work Permit and Associated
Clearances to the Permit Issuer when work is stopped for whatever reason.
2. The work activity shall be stopped when:
 An alarm is sounded; or
 An incident, accident or near miss occurs; or
 The Scope of Work changes; or
 New hazards develop; or
 The validity of the SWP expires
3. When the Emergency Alarm sounds, all work shall stop and any motorized equipment
shutdown. All personnel will exit the work area in a safe manner and report to their
assigned assembly point unless instructed otherwise.
Section 7 – Approvals
Print Name Signature Date Time
Area Owner
Permit Receiver
Permit Issuer