Sequence of Basic Job Steps Potential Hazards of Each Job Step Plan of Action To Control or Eliminate Any Hazard(s)

JOB HAZARD ANALYSIS WORKSHEET
Job/Task: THIS DOCUMENT IS REQUIRED DAILY
Job Location: Date:

Completed By:
Contractor: Supervisor / Foreman:
KM Representative:
Personal Protective Equipment required:
Discuss KM’s Incident and ERL reporting requirements:
Plan of Action to Control

Sequence of Basic Job Steps Potential Hazards of Each Job Step
or Eliminate any Hazard(s)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Signatures of Employees Verifying the Review of Potential Hazards

Print Name Signature Print Name Signature
IDENTIFY HAZARDS: Potential Examples:  striking against, being struck by, or making harmful contact with an object;  being caught in, by or between objects;
 slipping, tripping or falling;  developing a strain from pushing, pulling, lifting, bending or twisting;  coming in contact with electricity or other power source;
 receiving a thermal or chemical burn;  being exposed to a hazardous environment  vehicles (placement, backing, etc.)  valve operation authorization requirements
Distribution: KM onsite Representative Page 1 of 2 CSM-004

KM Job File Revised: 1/2013
Reviewed: 11/14/2017
INSTRUCTIONS FOR COMPLETING JOB SAFETY ANALYSIS WORKSHEET
Plan of Action to Control

Sequence of Basic Job Steps Potential Hazards of Each Job Step
or Eliminate the Hazard(s)
Break the job down into steps. Each of the steps of Identify the hazards associated with each step. Using the first two columns as a guide, decide what
a job should accomplish some major task. The task Examine each step to find and identify hazards - actions are necessary to eliminate, minimize, or
will consist of a set of movements. Look at the first actions, conditions and possibilities that could lead to monitor the hazards that could lead to an accident,
set of movements used to perform a task, and then an accident. Number hazard list to correspond with injury, or occupational illness.
determine the next logical set of movements. For your steps.
Number the actions to correspond with the steps and
example, the job might be to move a box from a truck
It is not enough to look at the obvious hazards. It’s identified hazards.
in the receiving area to a shelf in the storage area.
also important to look at the entire environment and
How does that break down into job steps? Picking Among the actions that can be taken are:
discover every conceivable hazard that might exist.
up the box from the truck and putting it on a hand
(1) engineering the hazard out
truck is one logical set of movements, so it is one job Be sure to list health hazards as well, even though
step. Everything related to that one logical set of the harmful effect may not be immediate. Ex: the (2) providing personal protective equipment
movements is part of that job step. harmful effect of inhaling a solvent or chemical dust
(3) job instruction training
over a long period of time.
The next logical set of movements might be pushing (4) good housekeeping
the loaded hand truck to the storeroom. Removing It’s important to list all hazards. Hazards contribute
the boxes from the truck and placing them on the to accidents, injuries and occupational illnesses. (5) good ergonomics (positioning the person in
shelf is another logical set of movements. And relation to the machine or other elements in the
In order to do Part 3 of a JHA effectively, you must
finally, returning the hand truck to the receiving area environment in such a way as to eliminate stresses
identify potential and existing hazards. That’s why and strains)
might be the final step in this type of job.
it’s important to distinguish between a hazard, an
Be sure to list all the steps in a job. Some steps accident and an injury. Each of these terms has a List recommended safe operating procedures on the
might not be done each time - checking the casters specific meaning: form, and also list required or recommended
on a hand truck, for example. However, that task is personal protective equipment for each step of the
HAZARD: A potential danger. Oil on the floor is a
a part of the job as a whole, and should be listed and job.
hazard.
analyzed. Be specific. Say exactly what needs to be done to
ACCIDENT: An unintended happening that may
Number the steps. The number will provide a correct the hazard, such as “lift, using your leg
result in injury, loss or damage. Slipping on the oil is muscles”. Avoid general statements like, “be careful”.
reference point for the hazards and procedures
an accident.
developed. Give a recommended action or procedure for every
INJURY: The result of an accident. A sprained
hazard.
wrist from the fall would be an injury.
If the hazard is a serious one, it should be corrected
Some people find it easier to identify possible
immediately. The JHA should then be changed to
accidents and illnesses and work back from them to
reflect the new conditions.
the hazards. If you do that, you can list the accident
and illness types in parentheses following the
hazard. But be sure you focus on the hazard for
developing recommended actions and safe work
procedures.
Distribution: KM onsite Representative Page 2 of 2 CSM-004

KM Job File Revised: 1/2013
Reviewed: 11/14/2017

Sequence of Basic Job Steps Potential Hazards of Each Job Step Plan of Action To Control or Eliminate Any Hazard(s)

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JOB HAZARD ANALYSIS WORKSHEET

Job/Task: THIS DOCUMENT IS REQUIRED DAILY

Job Location: Date:

Plan of Action to Control

Signatures of Employees Verifying the Review of Potential Hazards

Distribution: KM onsite Representative Page 1 of 2 CSM-004

Plan of Action to Control

Distribution: KM onsite Representative Page 2 of 2 CSM-004

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