Wolverine Builders - JHA Form

Date

Month

Day

Year

Project Name*

Prepared By:

Company name*

First name*

Last name*

Hazard Evaluation

Describe Tasks or activity being analyzed

Hazard Type*

Falls from heights

Struck by Hazards

Electrical Hazards

Caught in or Between Hazards

Chemical Exposure

Other

Describe Hazard if Other

Severity or Likelihood of Hazard*

High

Medium

Low

List controls to eliminate or reduce each hazard - (PPE,guardrails, training, etc.)

Person Responsible for implementing controls

First and Last Name*

Signature

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