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JOB HAZARD ANALYSIS (JHA) FORM (Elevated Work Will Be Required)

Complete daily before beginning work and review when work is complete. A copy of a site evaluation report
shall remain on site for the duration of a project.
Your Company Name: Customer

Competent Rigger or
Date: Supervisor

Job Number: Project Manager

Job Name: Emergency Contact

Job Address:

Nearest Intersection:

Latitude: Longitude:

EMERGENCY CONTACT INFORMATION

Hospital Name: Hospital Address:

Hospital Phone:

Directions to Hospital (see attached map) :

Elevated Rescue Procedures to be used:

Fire Department In-House Crew properly trained in tower rescue Third Party

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Typical Job Hazard Analysis (JHA)

The purpose of this form is to assist in reviewing the hazards on a job site and any nearby hazards that
personnel may be exposed to while completing a job.
Part 1 Jobsite Information
Type of Structure:
Metal Light Pole Rooftop/Side of Building Guyed SST
Other
DAS Structure Highway Sign Structure Monopole Water Tank
Type of Work: (Check all that apply)
TOWER: Construction Reinforcement Line/Antenna Work Maintenance Testing
CIVIL: Excavation Site Development Tower Foundation Slab Testing
ELECTRICAL: Conduit Meter/Panel Obstruction Lighting Grounding Wiring Testing
OTHER:
Job/Tasks: Potential Hazards Preventative Measures:
(List jobs in sequential steps) (List hazards for each step) (List each control for each hazard)

Part 2 Structural Hazard Check List

Is there a recent inspection report/structural analysis of the structure? Yes No N/A
Did you check all guys and their associated anchors for corrosion? Yes No N/A
Did you check all guys and the structure for plumb and tension? Yes No N/A
Have you visually inspected the tower's condition before climbing? Yes No N/A
Describe

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Part 3 Overall Hazard Check List

Have you checked for overhead power lines? Yes No N/A
Do you have the proper PPE for the hazards on site? Yes No N/A
Have you inspected the site for fall protection hazards and do you have the
applicable equipment on site to mitigate those hazards? Yes No N/A
Do you have a documented site-specific rescue plan on site? Yes No N/A

Have you reviewed the RF & EME hazards of the site? Yes No N/A
Are there First Aid/CPR certified individuals on site? Yes No N/A
Job Site Exposures and Hazard Identification (Check the Hazards):
Items checked below relate to existing conditions or may be a result of site operations.
Physical Hazards Health Hazards
Falls from Elevations Electrical Shock Heat Stress Cold Stress
Heavy Equipment Slips, Trips, or Falls High Noise (> 85 dBA) Chemical Exposure
Underground Utilities Overhead Utilities Silica Exposure (Concrete Cutting)
Vehicle Traffic Elevation/Site Terrain RF/EME Lifting Hazard
Other Workers on Site Fire Hazards Biological Lead Paint
Holes and Trenches Lacerations, Abrasions Birds / Animals / Insects / Reptiles / Plants
Trash, Debris, Dunnage High Crime Area Asbestos Containing Materials
Welding Intrusive Activity
Confined Space
Other
Falling Objects Other

Have you reviewed MSDSs for hazardous substances that might be present at the job site?
Hazard Control Measures (Check the Control Measures)
Required PPE Inspections Safety Training/Programs Site Security
Head Protection Tools/Equipment Tailgate Meeting Inner City
Foot Protection Rigging Site Signage Rural
Eye Protection Housekeeping RF Safety Awareness Night Work
Hearing Protection Tag Lines Lockout / Tagout Locked Access
Hand Protection Ground Fault Equipment Operation Lighting
Fall Protection Gin Poles Building/Rooftop Access
RF Monitors Hoists Barricades
RF Suits Call Before Digging
Face/Dust Mask Other

Work Clothing Other

Other
First Aid
Other

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Required Permits and/or Plan Requirements for your Company or Client

Hoisting Personnel Personnel Lift (Manbasket Descent Control Hoist/Gin Pole Capstan Hoist
Crane Lift Confined Space Excavation Hot Work Lockout/Tagout
Other
Have all applicable notifications related to permits been made Yes No N/A
Electrical Rooftop
Electrical Tools Lockout/Tagout Personal Fall Arrest Anchorage System
Electrical Test Equip Elec Equip Inspection Warning Line System Skylight Barricades
GFCI Electrical PPE Guard Rails / Parapet
Other Other
ALL TASKS
Describe the elevation, site terrain and environmental hazards:

Describe hazards with site/vehicle access (i.e. boom and cranes/electrical lines) and storage of materials:

Describe the overhead and underground electrical hazards:

Describe
other:
Complete for Civil Work
Describe cave-in control measures for personnel in excavations greater than 5' deep
Sloping Benching Shoring Shield Box Other:
Ladder System (if 4 feet deep or greater) every 25 feet of length. Must extend 36 inches above landing.
Describe
other:
Complete for Elevated Work
Describe cave-in control measures for personnel in excavations greater than 5' deep
Full Body Harness Double Leg or 2 Lanyards Rope Grab Cable Grab
Retractable Lifeline Anchorage Straps Rope Descenders Boatswains chair
Ladder safety Climb
Has each employee inspected his or her fall protection equipment? Yes No N/A
Is all gear in rescue bag or container present and operable at the base of tower or elevation? Yes No N/A
Hoisting Equipment to be used (if applicable): Yes No N/A
Base Mounted Hoist Crane/Boom Truck Gin Pole Suspended Basket Aerial Lift Device
Is the Suspended Personnel Platform Checklist and Critical Lift Plan completed and on site? Yes No N/A
Does the hoist comply with the regulations for lifting personnel? Yes No N/A
Are there adequate radio communications from tower to ground? Yes No N/A

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THE LAST 5 MINUTES The “Last Five Minute” is intended to be a quick assessment of the site before leaving
Check the box next to each item if it is satisfactory. As You Leave the Site
Is the logbook signed and NOC notified (if applicable)?
Is the construction area secured (i.e., fenced, barrier tape, warning signs, etc.)?
Are all trenches covered and/or barriers in place?
Is any material or equipment left in an unsafe suspended condition?
Are the shelter, gang boxes, and/or equipment doors closed and secured/locked?
Are the warning / no trespassing signs visible?
FlNALLY; Did I lock the gate when I left the site?
The "Last Five Minutes" sets the stage for how the client and others will view the site when they arrive.
Personnel
CPR/First Tower/
Certified
Name Company Aid Rescue Initials
Climber
Trained Trained

Job Hazard Analysis discussed and reviewed with all crew and other contractors on site? Yes No

Competent Rigger or Supervisor Signature Date

Development of this JHA:
At the request and assistance of many of the country's leading companies in the wireless infrastructure industry,
WirelessEstimator.com developed this best practices document to cover the most commonly required disciplines in
wireless construction. This JHA meets and exceeds all project JHA requirements set forth in ANSI/TIA-1019-A's
Check List for Site Evaluation for projects.
Use of this JHA:
By using this JHA, you acknowledge and agree that there may be other hazards that must be evaluated and you shall
hold harmless and indemnify Wireless Estimator, Inc. against any losses, liabilities and claims arising out of or
relating to the use of this document.
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