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JHA PDF SubButton .pdf


Original filename: JHA PDF SubButton.pdf
Title: JHA QCR SIR Blank.xlsx
Author: gpena

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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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