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THA Form


JOB INFORMATION

Date:*
Job Number:*
Job Name:*
Physical Address:*
Job Location:*

Have We Considered

Work Procedures People PPE Tools/Equip Special Precautions
  • Isolation of equipment.
  • Check for potential voltage.
  • Adequate grounding.
  • Vehicle grounds.
  • Working clearances.
  • Dig safe/call before you dig.
  • Worker fatigue.
  • Have all employees signed THA.
  • Have other Contractors Onsite been ask to sign our THA to make them aware of our hazards.
  • Public safety Pedestrian Control Other utilities.
  • Hard hat
  • Safety Glasses
  • FR Clothing
  • Rubber gloves
  • High visibility vest
  • Arc Flash Suite
  • Inspection Sheets.
  • Live line tools
  • Fall protection equipment.
  • Inspections of tools/equip.
  • Adjacent structures
  • Condition of structures
  • Weather conditions
  • Lightning in the area
  • Lighting conditions indoor/outdoor.
  • Terrain /Water Ways
  • Spills and leaks
Clearance:
 YES  NO 
Clearance Holder Name:
Phone #:
Clearance #:
Boundaries:

Boundaries must be walked with anyone coming on site

Hazard Identification: Items Checked below relate to existing conditions or may be result of the site operation:

Physical Hazards
Health Hazards
 1.Confined Space  Permit Required
 2.Electrical/Clearance and Boundries
 3.Elevation/Site Terrian
 4.Aerial Equipment Operation
 5.Fire Hazards/Hot Work Permit
 6.Moving Shifting Loads
 7.Struck by/Contact with
 8.Overhead Work
 9.Slips,Trips or Falls
 10.Underground Utilities
 11.Vehicle/Equipment Traffic
 12.Other
 13.Chemical Exposure
 14.Cold Stress/frost bite
 15.Asbestos/Lead etc.
 16.Heat Stress/Sun Exposure
 17.High Noise (85 dBA)
 18.Lifting Hazards
 19.Silica Exposure (Concrete/Stone)
 20.Biological Hazards: Animals/insects snakes etc.
 21.High Dust Exposure
 22.Other:
Task
Hazard
Hazard Mitigations

SEE BACK OF PAGE FOR SIGNATURE SECTION

REVIEWS AND SIGNATURES

NAME AND SIGNATURE OF PERSON LEADING JOB BRIEFING

Name:
Signature:
 Clear signature

Sign only if you fully understand the work procedures and your role in this job. Remember: Everyone has a responsibility to stop unsafe work.

PROJECT PERSONNEL ACKNOWLEDGEMENT ( ALL AFFECTED PERSONNEL SIGN AFTER JOB BRIEFING )

Name:
Company:
Signature: