Job Hazard Analysis and Tool Box Discussion Form

JHA No H007 – “Servicing Isolated NLV Staterooms”

Department: HotelDepartment Job Description
Cleaning isolated staterooms which are
Responsible Supervisor: Chief/Asst Housekeeper
occupied by guests with NLV symptoms.
Date:
     

HAZARDS AND CONTROL MEASURES

No Description of Hazard. Description of measures taken to control the hazard.
1 Skin contamination from NLV. Disposable gloves to be worn.

2 Inhalation of contaminant NLV. Disposable mask to be worn.

3 Clothes contamination from NLV. Disposable apron to be worn.

4 Contamination outside of Stateroom. Shoe covers to be worn.

PERSONAL PROTECTIVE EQUIPMENT REQUIRED

Personal Protective Equipment to be used:

If additional PPE is required, list below:

 TOOLBOX DISCUSSION FORM Work Permit Completed if required? JHA Reviewed/Discussed?

Signs or Barriers in place and area roped off where required?

Any additional instructions required? If so, give details:

       

Are all persons involved in the task satisfied that there

are sufficient control measures in place to reduce all YES NO
risks to a tolerable level to complete the work?    

By signing below I acknowledge that I have discussed and understood the safety requirements for the above task:
       

Employee Name:   Employee Signature: 

Employee Name:   Employee Signature: 

Employee Name:   Employee Signature: 

Employee Name:   Employee Signature: 

Employee Name:   Employee Signature: 

Employee Name:   Employee Signature: 

Employee Name:   Employee Signature: 

Employee Name:   Employee Signature: 

Employee Name:   Employee Signature: 

Employee Name:   Employee Signature: 

By signing below the supervisor confirms that the job has been inspected at the work place and it is safe to continue with the work.

Supervisor Name:     Supervisors Signature: