(INSTRUCTIONS)

Example
JOB HAZARD ANALYSIS WORKSHEET
Organization:
(List the Department or
Major Organization)

Division:
(List the next level of
the organization)

Section/Shop:
(List the specific unit,
shop or section.)

Installation Security
and Safety

Safety Division

Traffic Safety

Task: (List the specific task to be completed.)

Transport and setup the Seatbelt Convincer.
Conducted By:
(Worker or Work Center
Safety Representative)

Reviewed By:
(Unit Safety Officer or
Safety Manager)

Approved By:
(Division Head, Manager
or Supervisor)

Date:

Date:

Date:

Sequence of Steps

Potential Accidents or
Hazards

Preventative Measures

(List all steps of the

work process in
sequence. Be specific.)

(List all potential

hazards for each step of
the work process.)

1. Move the vehicle to the

Convincer.

1. Damage to the vehicle or

injury to personnel due to
equipment failure or an
accident.

(List all preventive

measures to prevent or
reduce the risk or
hazard, to include a
step by step procedures
or any required PPE.)

2. Connect the convincer to

the vehicle.
3. Transport the convincer to
the site.
4. Position the convincer at
the site.
5. Disconnect the convincer
from the vehicle.
6. Return vehicle to original
site.

2(a). Damage to vehicle or

convincer when backing up the
vehicle to connect the convincer
to the hitch.
2(b). Back injury due to
incorrect lifting of the
convincer.
2(c). Hand or fingers injury
when connecting the convincer to
the tow ball of the hitch.
3. Damage to the vehicle or
injury to personnel from an
accident.

Ensure two personnel are

available to complete this
work process.
1(a). Ensure personnel are
properly licensed to operate
the vehicle.
1(b). Inspect the vehicle for
damage and serviceability
using the Vehicle Inspection
checklist.
2(a). Ensure the convincer
trailer tongue jack is raised
to a position above the
trailer ball.

5a. Back injury due to incorrect

lifting of the convincer.

2(b). Use a guide when backing

up the vehicle to the
convincer. Ensure that the
guide and driver have agreed
on what signals will be used
when backing up the vehicle to
the convincer.

(Continued)

(Continued)

4. Damage to the vehicle or

injury to personnel when moving
the convincer with vehicle to
the setup position.

Copies: 1-Maintain a copy at the applicable work center and

that it is readily available to employees.
2-Maintain a copy with the Unit Safety Office.
3-Provide a copy to the Base Safety Office.