Job Hazard Analysis Name * First Name Last Name Email * Phone Number * (###) ### #### Date * MM DD YYYY Time * Hour Minute Second AM PM Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Wind Direction * The wind is coming from the: North North-East North-West East West South South-East South-West Scope of Work * Required PPE * Check all that apply: Hard Hat Safety Glasses Steel Toe Boots FR Clothing Gloves Hearing Protection High Visibility Outerwear Respirator Other Other Individuals On The Job Job Task / Step 1 * Potential Hazards 1 * Mitigation / Controls 1 * Job Task / Step 2 * Potential Hazards 2 * Mitigation / Controls 2 * Job Task / Step 3 * Potential Hazards 3 * Mitigation / Controls 3 * Job Task / Step 4 * Potential Hazards 4 * Mitigation / Controls 4 * Job Task / Step 5 Potential Hazards 5 Mitigation / Controls 5 Job Task / Step 6 Potential Hazards 6 Mitigation / Controls 6 Emergency Contact Name * First Name Last Name Emergency Contact Number * (###) ### #### Other Information Signature * By typing my name below, I confirm that i have reviewed this JHA, understand the hazards and control measures associated with this work, and agree to follow all safety procedures relevant to this work. I acknowledge my responsibility to stop work and report any unsafe conditions or changes. I also confirm that all other individuals involved in this work have been made aware of this JHA and its contents. First Name Last Name JHA Submitted for Review. Thank you for working safe!
