JHA Form

JHA

Subcontractor

Subcontractor Name

Completed By

Full Name

Date

Time

Supervisor:

Job Name

Job Description

Instructions: Please complete the safety checklist below.

Work Hazard Identification

Are the following HAZARDS present on your Job site?

Slip/Fall/Trips

Yes

No

Pinch points

Yes

No

Struck By Hazards

Yes

No

General Electrical Hazards

Yes

No

Shock/ Arc Flash

Yes

No

Cuts

Yes

No

Elevated Work (Lifts, Scaffolds, Ladders, Roofs)

Yes

No

Hazardous chemicals (sealants, solvents, foams, fuels, etc..)

Yes

No

Lifting (Material Handling, Rigging)

Yes

No

Noise

Yes

No

Personal Protective Equipment (PPE) Requirements

Do you have the following list of PPE available to you for use?

Are you using any Fall Protection equipment today?

Yes

No

Have you inspected the following equipment and are they in good working order?

Harness (Check stitching and buckles, etc)

Yes

No

Decelerator "Shock Pack"

Yes

No

Trauma Strap

Yes

No

Life Line "Rope"

Yes

No

Rope Grab

Yes

No

Carabiner(s)

Yes

No

Roof Attachment Anchor

Yes

No

Horizontal Life Line

Yes

No

Cross Arm Strap

Yes

No

Self Retracting life lines

Yes

No

Auxiliary Lanyard

Yes

No

Parapet wall clamp anchors

Yes

No

Guard Rail System

Yes

No

Guard Rail System

Yes

No

Tool Inspection

Powers Tools, GFCI and extension cords in good working condition

Yes

No

Will you be using a ladder today?

Yes

No

What type of ladder are you using?

Step

Extension

Both

General Ladder Safety

Have you completed the following safety precaution checks?

Has the ladder been altered?

Yes

No

Is the integrity of the ladder compromised by the weather?

Yes

No

Housekeeping of Ladder. (Is the top and bottom of your ladder clear of obstruction?)

Yes

No

Rungs and boots clean of oil, mud or ice

Yes

No

Feet are positioned in the middle of the rung

Yes

No

Proper precautions taken when working adjacent to live power

Yes

No

Maintaining 3 points of contact

Yes

No

Overhead obstructions Eliminated

Yes

No

Are you setting your ladder up on stable and non slippery surface?

Yes

No

Facing ladder at all the times

Yes

No

Step Ladder Inspection

Steps: Loose, Cracked, bent, Missing

Yes

No

Labels: Missing or not readable

Yes

No

Top: Cracked, Loose, Bent, Broken

Yes

No

Spreader: Loose, Bent, Broken

Yes

No

General: Rust, Corrosion, Loose Parts

Yes

No

Bracing, Shoes and Rivets in good condition

Yes

No

Other

Yes

No

Details

Extension Ladder Inspection

Rungs: Loose, Cracked, Bent, Missing

Yes

No

Rails: Cracked, Bent, Split, Frayed

Yes

No

Labels: Missing, Not readable

Yes

No

Hardware: Missing, Loose, Broken

Yes

No

Shoes: Worn, Broken, Missing

Yes

No

Rope/Pulley: Loose, Bent, Broken

Yes

No

Rope/Pulley: Loose, Bent, Broken

Yes

No

General: Rust, Corrosion, Loose

Yes

No

Extended: 3' above landing

Yes

No

Tie Off: Ladder is tied off to prevent tipping

Yes

No

Positioning: 4:1 Ratio maintained

Yes

No

Reach: Stay within the frame of the ladder

Yes

No

Height: Provides adequate height/access

Yes

No

Additional Safety Measures

Did you warm up and stretch?

Yes

No

Lockout Tagout necessary:

Yes

No

Energized Work Permit necessary:

Yes

No

Emergency Plan/Rescue Plan/Nearest Urgent Care Located

Yes

No

Emergency Plan reviewed:

Yes

No

Nearest fire extinguisher located:

Yes

No

First aid kit

Yes

No

Additional Notes

Signature

Clear

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