Job Hazard Analysis Form
[Type text]
Work Process, Area or Job:
Department:
JHA developed by:
Date:
Page __of__
JHA Approved by:
Review Date:
Required Personal Protective Equipment:
Assess
Safety Office
Risk Rating
(H,M,L)
Consequence(
1-5)
Probability (AE)
Potential Hazard
Occurrence (16)
Recognize (Basic Steps)
Exposure (1-6)
Risk Evaluation (see back of form)
Control
In place?(y/n)
Document1
Job Hazard Analysis Form
[Type text]
Page __of__
Work Process, Area or Job:
Assess
Safety Office
Risk Rating
(H,M,L)
Consequence(
1-5)
Probability (AE)
Potential Hazard
Occurrence (16)
Recognize (Basic Steps)
Exposure (1-6)
Risk Evaluation (see back of form)
Control
In place?(y/n)
Document1
Job Hazard Analysis Form
[Type text]
Page __of__
Work Process, Area or Job:
Assess
Safety Office
Risk Rating
(H,M,L)
Consequence(
1-5)
Probability (AE)
Potential Hazard
Occurrence (16)
Recognize (Basic Steps)
Exposure (1-6)
Risk Evaluation (see back of form)
Control
In place?(y/n)
Document1
Job Hazard Analysis Form
[Type text]
Page __of__
Work Process, Area or Job:
Assess
Safety Office
Risk Rating
(H,M,L)
Consequence(
1-5)
Probability (AE)
Potential Hazard
Occurrence (16)
Recognize (Basic Steps)
Exposure (1-6)
Risk Evaluation (see back of form)
Control
In place?(y/n)
Document1
Job Hazard Analysis Form
[Type text]
Page __of__
Work Process, Area or Job:
Assess
Safety Office
Risk Rating
(H,M,L)
Consequence(
1-5)
Probability (AE)
Potential Hazard
Occurrence (16)
Recognize (Basic Steps)
Exposure (1-6)
Risk Evaluation (see back of form)
Control
In place?(y/n)
Document1
Job Hazard Analysis Form
[Type text]
Page __of__
Risk Evaluat io n:
Exp o sure: W hat is t he
likelihood of exp osure?
Occurrence: W hat is t he likelihood o f
an injury/ incid ent ?
1. Cont inuous
2. Freq uent (d aily)
3. Occasional (13x/ w eek)
4 . Unusual (13x/ m ont h)
5. Rare (1-6x/ year)
6 . Very rare (y early or
less)
1.
2.
3.
4.
5.
6.
Very likely (has hap p ened / is
exp ect ed )
Likely (p rob ab ly – it could
hap p en)
Rare (seld om b ut p ossib le)
Very rare (very seld o m b ut
p ossib le)
Very unlikely ( slig ht p o ssib ilit y)
Pract ically im p o ssib le
Exp osure ( 1-6) + Occurrence ( 1-6) = Prob ab ilit y ( A -E)
Co nseq uences: W hat are t he conseq uences?
1. Fat alit y or p erm anent d isab ilit y,
sig nificant p rop ert y loss ($50 0 k+)
2. Crit ical Injury or illness w it h lost t im e,
m ajor p rop ert y loss ($50 k-$50 0 k)
3. Mod erat e injury or illness w it h lost t im e,
m od erat e p rop ert y loss ($5k-$50 k)
4 . Minor injury or illness w it hout lost t im e,
m inor p rop ert y loss (<$5k)
5. No injury, illness, lost t im e or p rop ert y
loss
Prob ab ilit y ( A -E) + Conseq uences ( 1-5) =
Risk Rat ing ( L, M, H)
Pro b ab ilit y:
1
2
3
4
5
6
1
A
A
B
C
C
D
2
A
B
B
C
D
D
3
B
B
C
D
D
D
4
B
C
C
D
D
E
5
C
C
D
D
E
E
6
C
D
D
E
E
E
Safety Office
A . Com m on or
rep eat ing o ccurrence
B. Likely
(p rob ab le – it co uld
hap p en)
C. Could occur
(or “ I’ve heard of it
hap p ening )
D. Not likely t o
occur
E. Pract ically
im p ossib le
Pro b ab ilit y
Co nseq uences
Exp o sure
Occurrence
A
B
C
D
E
1
H
H
H
M
M
2
H
H
M
M
L
3
H
M
M
L
L
4
M
M
L
L
L
5
M
L
L
L
L
H - Hig h a serious or sig nificant hazard req uiring im m ed iat e
correct ive act ion
M – Med ium req uiring cont rol m easures as soon as p ossib le
L – Low t o b e ad d ressed aft er hig her p riorit ies
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