JOB HAZARD ASSESSMENT __ ___________________________ _____________________________________ _______________________ OCCUPATION / JOB TITLE NAME: PERSON CONDUCTED JHA JOB ASSESSED ____________________________ _____________________________________ ______________________________ DEPARTMENT SIGNATURE: PERSON CONDUCTED JHA DATE JHA WAS CONDUCTED STEP TASKS POTENTIAL HAZARDS RISK ASSESSMENT REMEDIATION MEASURES Specify each task required to complete the job Note: There may be multiple hazards in each Step. Check all that apply OTHER 1 2 3 4 5 6 7 8 9 10 11 12 Note: You will probably have to estimate these parameters. Severity of Risk Exposure: Use a scale of 0 - 6. 0: No injury or Illness or quality, production or other loss of less than $100. 2: Minor injury or illness without lost time; non-disruptive property damage; quality, production, environmental or other loss $100 - $1000. 4: A loss time injury or illness without permanent disability; disruptive property damage; quality, production, environmental of loss more than $1000 but not more than $5000. 6: Permanent disability; loss of life or body part; extensive loss of structure, equipment, material; quality, production, environmental or other losses exceeding $5000 Frequency of Exposure: Use a scale of 1 -3. 1: Few times a day 2: Several times per day 3: Many times per day Probability