Name (individual completing JHA) *

First Name

Last Name

Date

MM

DD

YYYY

Pit Work *

Yes

No

Scaffolding Required *

Yes

No

Hoisting & Rigging Used *

Yes

No

Rigging Plan Completed *

Yes

No

PPE: *

Fall Protection (Hardness and Lanyard)

Bump Cap

Hard Hat

Goggles

Cotton Sleeves

LOTO Gloves

Lockout Tagout Equipment

Reflective Vest

Hearing Protection

Dust Masks