Job Hazards Safety Analysis

TWT INVOICE #

TWT TRUCK #*

TWT EMPLOYEE*

Customer Info / Location

Customer info, & Location of incident & type of incident.

CUSTOMER NAME*

Date*

Phone*

CONTACT NAME*

First Last

LOCATION*

DESCRIPTION OF WORK*

POTENTIAL HAZARDS: (CHECK ALL THAT APPLY)

POTENTIAL HAZARDS*

Select All
LIFTING HAZARDS
SLIPS/TRIPS/FALLS
PINCH/CRUSH/STRIKING
HAZARDOUS CHEMICAL/GAS EXPOSURE (H2S)
SKIN IRRITANTS
ENVIRONMENTAL EXTREMEMS
FIRE OR EXPLOSION POTENTIAL
CONFINED SPACE

POTENTIAL HAZARDS*

Select All
ELEVATED LOAD OR WORK
OVERHEAD OBSTRUCTION
SHARP EDGES OR HOT/COLD SURFACES
STATIC ELECTRICITY
FLYING DEBRIS
HIGH NOISE LEVELS
SHORT SERVICE EMPLOYEE
OTHER

APPLICABLE SAFE WORK PRACTICES (CHECK ALL THAT APPLY)

APPLICABLE SAFE WORK PRACTICES*

PRE-JOB SAFETY DISCUSSION
SITE/JOB ORIENTATION
CRITICAL LIFT PLAN
WHEEL CHOCKS/ORANGE CONES IN PLACE
USE OF SPECIALIZED PPE (NOMEX,FRC)
COMMUNICATIONS, PROCEDURES, PHONE #S (NO CELL PHONE USE ON LOCATION)
USE OF BARRICADES
SIGNAGE IN PLACE

WEATHER/ENVIRONMENTAL CONDITIONS*

FAIR
HOT
COLD
WINDY
PRECIPITATION
ICE
LIGHTNING
OTHER

List & discuss basic job steps, the potential hazard of each step & associated consequences, the severity rate of the hazards & the recommendation to eliminate or reduce hazards.

BASIC JOB STEPS*

POTENTIAL HAZARDS & CONSEQUENCES*

RECOMMENDATION TO ELIMINATE OR REDUCE HAZARDS*

SEVERITY RATE*

LOW
MODERATE
HIGH

DISCUSSION TOPICS

Do all personnel underst& the hazards of the job(s)/process(es) & the applicable safe work practices (e.g. proper tools & equipment, permitting requirements)?*

YES
N/A

Have you verified that all required permits (i.e. hot work, confined space entry, energy isolation) are in place & that all employees underst& the guidelines governing their use?*

YES
N/A

Have you thoroughly inspect all safety equipment, tools & machinery available at the work site for reliability & safe operation?*

YES
N/A

Are all personnel adequately trained to safely perform their duties & have full underst&ing of the site emergency action plan & radio/telephone locations?*

YES
N/A

EMERGENCY ACTION PLAN

AMBULANCE:

HOSPITAL:

FIRE:

SHERIFF/POLICE:

CUSTOMER'S ERP#

TWT SUPERVISOR#

OTHER

TWT EMERGENCY#

661-589-3808 MAIN OFFICE

DESCRIBE MUSTER POINT:

Was Emergency Response Plan & Action Reviewed & Agreed Upon?

YES
NO

IF NO GIVE REASON:

SIGNATURES ARE RQUIRED BY ALL PERSONS INVOLVED WITH THE WORK DESCRIBED ON THE JHSA

Signature*

TEN-WEST TOWING, INC. - JOB HAZARD/SAFETY ANALYSIS

PWR UNIT

TRLR

DRIVER

PWR UNIT

TRLR

DRIVER

PWR UNIT

TRLR

DRIVER

PWR UNIT

TRLR

DRIVER

CONSUMABLES

ADD THE QUANTITY & ITEMS

Notes

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Job Hazards Safety Analysis