JHA PDF SubButton .pdf
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Waterproofing
Caulking
FirestoppingSubmit
Moisture Protection
JOB HAZARD ANALYSIS FORM
Location:
Job Name:
Job Number:
Date
Company _
Prepared by:
Date:
Reviewed by:
Date:
1. Employees
Name
Certified or Trained
Y
N
By?
___
___
___
___
2. Equipment
Certified or Trained
Type
Y
N
___
___
3. Environmental Conditions (Check all that apply)
Wet
Heat
Cold
Outside
Inside
Vibration
By?
_
_
Dust
Vapor / Mist
Noise
Kneeling
Standing
Other (Explain)
4. Primary Job Functions & Position (Check all that apply)
Lifting
Pushing
Grasping
Bending
Reaching
Sitting
Other (Explain)
Pulling
Squatting
5. Physical Demands
Continuosly (C) 67-100%
Not Applicable (N) 0%
Standing
Pulling
Kneeling
Walking
Climbing
Reaching
___
___
___
6. Potential Hazards
Occasionaly (O) 1-33%
Sitting
Stooping
Carrying
___
___
___
Frequently (F) 34-66%
Pushing
Bending
Distance
___
___
___
___
___
___
Controlled by (Check all that apply)
Impact
PPE
Procedure
Training
Guards
Certification
Chemical Contact
PPE
Procedure
Training
Guards
Certification
Caught on or between
PPE
Procedure
Training
Guards
Certification
Fail or Slip
PPE
Procedure
Training
Guards
Certification
Over Exertion
PPE
Procedure
Training
Guards
Certification
Cumulative Trauma
PPE
Procedure
Training
Guards
Certification
Struck By
PPE
Procedure
Training
Guards
Certification
Fire Hazard
PPE
Procedure
Training
Guards
Certification
Other
PPE
Procedure
Training
Guards
Certification
7. List of Specific Hazards
8. Chemical List
9. Personal Protective Equimpent
Face
Eye
Respiratory
Hand
Head
Other
__
__
__
__
__
Foot
Clothing
Other
__
__
10. Procedure Step by Step - Record here and / or separate page and staple
George D. Alan Co
DALLAS
2205 Century Circle
Irving, Texas 75062
George D. Alan Co
AUSTIN
8403 Cross Park Dr, Suite 2A
Austin, TX 78754
Oklahoma Waterproofing Co
OKLAHOMA
1632 Linwood Blvd.
Oklahoma City, OK 73106
www.waterproof.pro
Texas Moisture Protection Co
HOUSTON
15003 Mintz Lane
Houston, Texas 77014
Seal-Co, Inc.
ALBUQUERQUE
2705 Pan American Freeway, Suite B
Albuquerque, NM 87107
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