St. Luke’s Health System
Department of Architecture & Construction
Construction Activity Safety Planning
Job Hazard Analysis: Date:Click here to enter text.
SL Project/Task: Click here to enter text. Supervisor: Click here to enter text. ☐Const. ☐BSD
St. Luke’s Health System
Department of Architecture & Construction
Company: Click here to enter text.
Supervisor: Click here to enter text.
Phone#: Click here to enter text.
Job Site: Click here to enter text.
Location: Click here to enter text.
Job Activity: Click here to enter text.
Date of Task to be performed: Click here to enter text.
JHA Completed by (Name): Click here to enter text.
Approved by: Click here to enter text.
Potential Hazards created by task
☐Eye☐Noise
☐ Respiratory
☐ Face/Neck
☐Foot
☐ Hands
☐Burns
☐Back
☐Pinch Points
☐Head
☐ Click here to enter text.
☐ Click here to enter text. / ☐Falls
☐Caught Between
☐Crushed by
☐Electrical
☐Cave in
☐Slips/Trips
☐Confined Space
☐Fire/Explosion
☐Heat/Cold
☐Falling Object
☐Chemical Exposure
☐Abrasion/Laceration
Equipment to be used and Inspected
☐Scissor Lift☐Scaffolding
☐Crane
☐Fire Extinguisher
☐ Click here to enter text.
☐ Click here to enter text. / ☐Aerial Lift
☐Cable Jack
☐ Forklift
☐Helicopter
☐Chain Hoist
☐Extended Reach Forklift
List Tools needed for task Inspected
Click here to enter text. / ☐Click here to enter text. / ☐
Click here to enter text. / ☐
Click here to enter text. / ☐
Click here to enter text. / ☐
Personal Protective Equipment to be used
☐Safety Glasses☐Goggles
☐Face Shield
☐Welding Helmet
☐Welding
☐Clothing
☐Ear Plugs/Muffs
☐Leather Gloves
☐Rubber Gloves
☐Apron
☐Respirator
☐ Click here to enter text. / ☐Hard Hat
☐Safety Vest
☐Reflective Vest
☐PFAS (Harness)
☐Safety Nets
☐Personal Floatation
☐Life Ring Buoy
☐Skiff
☐Chaps
☐Protective Footwear
☐ Click here to enter text.
Training Completed and Records on File
☐30 Hour Competent Person
☐10 Hour Competent Person
☐Certified Fall Protection
☐Forklift
☐Excavation and Trenching
☐Scaffolding Competent Person
☐Scaffolding Employee Awareness
☐Emergency Evacuation
☐Confined Space
☐Hazardous Communication
☐ St. Luke’s Contractor Training
☐ Click here to enter text.
St. Luke’s Health System
Department of Architecture & Construction
If you have checked a hazard on the first page, describe the task, hazard and the solution to eliminate.
Task / Hazard / SolutionName of person performing training on the JHA:
Employees names and signatures that have been trained on this JHA
Printed Name / Signature / Date of Training