Main Shop's Phone Number QC 563-285-7502 CR 319-364-1569 PRE JOB HAZARD ASSESSMENT

Safety Manager's Phone Number 319-550-4164 OUR GOAL IS ZERO INJURIES IN THE WORKPLACE
Revised 10/12/17
GENERAL INFORMATION ORIGINAL ISSUE DATE: BARRICADE REQUIREMENTS  N/A
PJHA Completed By: Revalidation Date: Rigid Railing Required  Cones  Covers Marked and Secure
Foreman/Supervisor: Revalidation Date:  Danger Tape or Caution Tape  Warning Signs Required
Job Site and Work Area: Revalidation Date: LOCKOUT/TAGOUT (Energy System Isolation Verified)  N/A
Job Name or Work Order #: Revalidation Date:  LOTO walked down with the Coordinator
SCOPE OF WORK:  Locks and tags installed
 Lock Box/Equipment #:
 Lock Box Location
 Equipment tested to verify the effectiveness of LOTO
MAIN TASKS ASSOCIATED WITH THIS JOB? SCAFFOLDS  N/A
1)  Scaffold Tags in Place
2)  Scaffold Inspected Daily/Per Shift/or Every 12 Hours?
3)  Yes  No - Have Revalidated
PLEASE LIST TOOLS/EQUIPMENT NECESSARY TO PERFORM JOB/TASKS (Inspect all prior to each use) OTHER SAFETY CONSIDERATIONS  N/A
 Have all other trades working in area been notifed of our work
 Need fire extinguisher  Need fire blankets
HAZARDS CONTROLS TO ELIMINATE HAZARD  N/A
REQUIRED PPE; CHECK ALL THAT APPLY  Slips/Trips
PPE For All Job Tasks: Safety glasses with side shields, gloves & work boots appropriate for task.  Pinch Points
SPECIAL EMPHASIS – PROPER GLOVES FOR TASK (CUT RESISTANT/WELDERS GLOVES/ETC)  Burns
 Hearing Protection  Welding Sleeves  Anchor Point  Rubber Boots  Cuts/Sharp Edges
 Hard Hat  Safety Vest  Arc Flash Protection  Dust Mask  Line of Fire
 Face Sheild  Safety Harness  Tyvek Suit  Respiratory Protection  Lifting/Pulling/Pushing
 Welding Hood  Retractable  Chemical Suit/Gloves/Boots  Difficult Access
 Other Protective Equipment/Clothing(Specify):  Weather/Lighting
ADDITIONAL PERMITS NEEDED  N/A  Fall from Heights Rescue Plan In The Event of A Fall:
 Confined Space  Rigging/Lifting  Lockout Tagout  Safety Device Bypass
 Elevated Work  Critical Lift  Ignition Source  Line Break  Other (Please Describe):
 Hot Work  Silica  Other (Specify):
Involved Crew Members: I have read and understand the above information and have received verbal instruction from my foreman/supervisor. I have also read and understand all the
necessary permits and safe work procedures required for this task. If revalidating permit, each person must redate next to their name below in order to certify this pjha as valid. SIGN & DATE
Legibly Sign Name Date/Reval Date Legibly Sign Name Date/Reval Date Legibly Sign Name Date/Reval Date
x x x
x x x
x x x
Foreman/Supervisor Signature Date/Reval Date PJHA Audited By: