JOB HAZARD ANALYSIS [JHA] WORKSHEET

JHA NO. PTW NO WORK PERMIT TYPE

FACILITY PLATFORM LOCATION EWDP-B SPECIFIC WORKSITE CHEMICAL INJECTION SKID

EQUIPMENT NO. WORK DESCRIPTION

TO CALIBRATE BIOCIDE INJECTION PUMP

JOB STEP

DESCRIPTION OF JOB STEP

POTENTIAL HAZARD

POTENTIAL CONSEQUENCES

CONTROL BARRIERS ACTION PARTY

RECOVERY BARRIERS ACTION PARTY

Internal Page 1

1

2

3

4

5

6

7

8

9

10

Internal Page 2

JHA APPROVAL DURING PTW APPLICATION

JHA NO.

PTW NO

WORK PERMIT TYPE

FACILITY

LOCATION

SPECIFIC WORKSITE

EQUIPMENT NO.

WORK DESCRIPTION

PRE-PREPARED JHA PREPARED BY

Name(s) Designation

WORK TEAM (CONFIRMATION THAT JHA HAS BEEN COMMUNICATED TO WORK TEAM AS PART OF PRE-JOB/TOOLBOX MEETING)

Name(s) Designation Signature Name(s) Designation Signature

WORK LEADER APPROVED BY

NAME NAME

DESIGNATION DESIGNATION

SIGNATURE SIGNATURE

DATE DATE