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Job Hazard Analysis Form - Simple Format Sub IDN

This document is a Job Hazard Analysis form that assesses risks and required safety measures for various tasks. It collects information such as the task, location, required permits, personal protective equipment, steps involved in the task, associated hazards, possible impacts, and necessary controls to prevent harm. The form is used to analyze tasks, implement controls, and document approvals, changes, and personnel acknowledgement of the analysis.

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andi
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336 views5 pages

Job Hazard Analysis Form - Simple Format Sub IDN

This document is a Job Hazard Analysis form that assesses risks and required safety measures for various tasks. It collects information such as the task, location, required permits, personal protective equipment, steps involved in the task, associated hazards, possible impacts, and necessary controls to prevent harm. The form is used to analyze tasks, implement controls, and document approvals, changes, and personnel acknowledgement of the analysis.

Uploaded by

andi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Job Hazard Analysis Form

Revision No. 1
Job Hazard Analysis: Date:
What is the task: Location:
Apa tugasnya : Lokasi :
Permit Type: ☐Electrical Work ☐Hot Work ☐Confined Spaces ☐ Excavation ☐ Working at Height (specify)
Permit Required: ☐Yes ☐No
☐ Others: _______________ _________________________________
Permit Approved: ☐Yes ☐No Permit Approved By:
Name of JHA Team Contact: Signature:
JHA Team sign on:
Name: Signature: Name: Signature: Name: Signature:

Name of JHA Checker: Signature:


Personal Protective Equipment (PPE) Required (Check the box for required PPE):

Face/Dust Hearing Appropriate Appropriate


Hard Hat Face Shield Eye Protection Overalls Hi –Vis Weld Mask
Masks Protection Footwear Gloves
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Oxy-Acetylene
Sunscreen Goggles
Harness Long-sleeves Respirator Others Others Others Others Others
Lotion

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
STEP TASK STEP HAZARD IMPACT CONTROLS
What am I doing what can hurt me / others or impact on the What harm could occur What must be in place to prevent harm ? (include
environtment specific responsibilities where applicable)
Langkah tugas apa yang Dampak apa yang dapat
akan saya lakukan Bahaya apa yang bisa melukai saya/orang menyebabkan kerugian Kontrol apa yang harus ada untuk mencegah
lain/berdampak pada lingkungan bahaya ? (Sertakan tanggung jawab spesifikasi jika
berlaku)
Change Management and Approval
Date & Time Step # Description of Change New Controls Change Approved
Sign On and Change Acknowledgement Register
Date Time Name Signature Date Time Name Signature

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