Job Hazard Analysis Worksheet Form

The form should be used in accordance with the Job Hazard Analysis Standard MS-AS-STD-0064

Project Details
Project Title
Customer Contract Title:
Contractor: Contractor Number:

Job Description Work Area / Equipment Sequential

(Brief Title) JHA No.

Supervisor to confirm that an HSE Risk Assessment has YES Proceed with JHA
been completed for the scope of work?
NO Do not proceed with JHA and do not commence works

Health and
Permits/Isolations  Energy Sources   Environmental  PPE 
Safety
Elevated Work Air Pollution
(dust, fumes,
Hot Work Electrical gas) Glasses
Moving parts Harm to Flora or Chemical
Confined Space Mechanical Fauna Goggles
Excavation / Mobile Noise (plant and
Penetration Manual Valves Equipment equipment) Face shield
Working from Hazardous Spills to drains /
Heights Pneumatics/Pressure Flora or Fauna waterways Dust Masks
Asbestos Removal Chemicals Fire Spills to ground Gloves
Working Alone Soil
High Voltage High Voltage erosion/quality Harness
Electrical Access Thermal Lighting Community Respirator
Working on Live Simultaneous Disposable
Equipment Vibration/Noise Operations Overalls
Slips/Trips/Falls Safety
harness/fall
Land Clearance Gravitational arrest
Biological Ergonomics
Radiation Air Quality

Hazardous Materials / Substances

(List any hazardous material to be used or present in the work area. Attach an SDS for each):

Effective Date at JESA: 20 January 2021 MS-AS-FRM-0063 Rev 0 01 May 2020

Job Hazard Assessment
CONTROLS
STEPS HAZARDS
Elimination

List the current and future control measures required

List the steps required to perform the task in the List the identified hazards that could cause Substitution
to eliminate or minimize the risk of injury/damage (use
sequence they are carried out injury/damage when the step is performed. Engineering
hierarchy of controls) Control

Administrati
ve Control

PPE

Effective Date at JESA: 20 January 2021 MS-AS-FRM-0063 Rev 0 01 May 2020

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 Supervisor to participate and sign as endorsement to
All Team Members to participate and sign as agreement with the JHA Worksheet: proceed with works

Name: Signature: Name: Signature: Name:

Signature:

Date:

Management Representative (as required)

Name:

Signature:

Date:

Effective Date at JESA: 20 January 2021 MS-AS-FRM-0063 Rev 0 01 May 2020

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