Permit #:__________	Project Start Date: __________
Company: __________	Work Area: __________	Project End Date: __________
Description of Work (Clearly Define Scope): __________

Please describe control and hazard prevention measures in Section F – Job Hazard Analysis for each item marked “Yes”. Please refer to Section C - Supplemental Documents for each shaded box marked “Yes”.
A. WORKER SAFETY:	Yes	No
Is barricading and signage required to protect personnel, facilities or equipment?	☐	☐
Will work involve live systems (e.g. hot tap) or energized electrical equipment?	☐	☐
Is Isolation (Lockout/Tagout or Tagout only) of hazardous energies required? Check type: ☐ electrical, ☐ hydraulic-pressurized, ☐ thermal, ☐ mechanical, ☐ chemical, ☐ pneumatic, ☐ radiation, ☐ stored energy, ☐ other: __________	☐	☐
Will work involve the use of a ladder?	☐	☐
Will work involve exposure to falls of 4 feet or greater? Check type: ☐ladders greater than 20 feet, ☐extended reach ladder activities, ☐scaffolding,☐workplatforms, ☐ boom lifts, ☐ scissor lifts, ☐ unguarded roof edge, ☐removing floor tiles or creating an open penetration, ☐other: __________	☐	☐
Will work take place underneath existing or potential overhead work?	☐	☐
Will work involve the use of a crane and/or hoist?	☐	☐
Will work involve handling of heavy material (guideline: greater than 25 lbs)? Check type of controls: ☐ two person lift, ☐ lifting device, ☐ Powered Industrial Truck (e.g. Forklift, electric pallet jack, etc.)	☐	☐
Will work involve ergonomic risks (e.g. vibration, forcefull exertion, static posture, contact stress, etc.) and/or awkward postures?	☐	☐
Will the task involve the use of chemicals or be adjacent to process equipment/piping containing chemicals?	☐	☐
Are Safety Data Sheets available for review by workers?	☐	☐
Are chemicals approved for use on-site as required by the Chemical and Material Screening Program?	☐	☐
Will containers be labeled with contents and hazards?	☐	☐
Will containers have a designated storage location?	☐	☐
Will work be occurring on or around a PSM covered process? (Coordinate with Safety Specialist and System Owner)	☐	☐
Will work generate ☐ odors, ☐ fumes or ☐ dust?	☐	☐
Will work generate waste or introduce material to an existing waste stream? (Coordinate with ESH Specialist)	☐	☐
Does the task require the demolition of systems or equipment? Check type: ☐ electrical ☐ chemical ☐ other: __________	☐	☐
Has the source disconnection been verified?	☐	☐
Will any stored energy be properly released? (e.g. capacitors)	☐	☐
Will the lines be verified via slip-ring process?	☐	☐
Will it involve demolition or removal through wall/floor/ceiling penetrations? If yes, note column location: __________	☐	☐
Will work involve preparing equipment for movement? No movement is authorized until the Orange Tag is IN PLACE.	☐	☐
Will work take place in designated arsenic or lead use areas? Check type: ☐ arsenic ☐ lead	☐	☐
Has the work been verified not to disturb Asbestos Containing Materials? (e.g. floor tile, mastic, piping insulation, wall board,etc.)	☐	☐
Will weather conditions affect the safe completion of this task?	☐	☐
Will work involve using sharp tools or materials (e.g. saws, knife, sheet metal, etc.)? List type: __________	☐	☐
Will work involve any activity which may produce a spark, arc or open flame such as cutting, welding, grinding, or chipping?	☐	☐
Will work involve employee exposure to hazardous noise levels ( >85 dB, need to yell to overcome noise)?	☐	☐
Will work restrict access to emergency equipment (e.g. Safety shower, eyewash, fire extinguisher) and/or egress pathway?	☐	☐
Will work involve potential impact to indoor/outdoor lighting levels?	☐	☐
Will work be conducted in a confined space?	☐	☐
Will work involve the use of a laser or other light emitting source (laser level)?	☐	☐
Will work occur in an environment where the worker cannot be seen, heard, or assisted in the event of an injury or emergency? (Working Alone)? If yes, specify in the JHA - Section F the communication plan.	☐	☐

Permit #:
B. RELIABILITY IMPACT:	Yes	No
Will the work involve or have the potential to impact:
Fire Detection and Suppression - Smoke Detectors IR/UV/VESDA, Sprinkler?	☐	☐
Safety Shower, Eye wash, Fire extinguisher, Leak detection?	☐	☐
Evacuation Speakers or Strobes?	☐	☐
Hazardous Gas/Bulk Chemical Distribution Systems?	☐	☐
Security/Life Safety Systems (Gas Detection)?	☐	☐
Ion Emitter / Particle Counter / Clocks / AMC Monitoring?	☐	☐
Process Controls (PLCs, SCADA, hardware, software)?	☐	☐
Will work involve climbing or standing on equipment or utility systems? If yes, specify: __________	☐	☐
Will work involve excavation, digging, drilling or driving materials into the ground?	☐	☐
Does the project involve an equipment move? If yes, provide drawings with your move path.	☐	☐
Do switches, buttons, pipes, gauges, or valves need to be protected or supported?	☐	☐
Has construction power been obtained from an approved non-process source?	☐	☐
Does the work require flushing or discharging of fluids or purging of gases? Note: Where there is a potential for cross-contamination, ensure a FCCB has been conducted.	☐	☐
Will work involve drilling, coring, or roto-hammering on facility structures?	☐	☐
Will work involve potential runoff into the storm drains? If yes, list how storm drains will be protected in the JHA – Section F.	☐	☐
Will work involve interruption or redirecting of vehicle or pedestrian traffic? (Coordinate with Security)	☐	☐
Will work involve potential impact to production tools (e.g. EMO/EPO buttons, gas or chemical lines, cables, hoses, valves, meters, or any work within the proximity of a tool)?	☐	☐
Will work impact or involve pollution abatement equipment? (Coordinate with ESH Specialist and system owner)	☐	☐
If work is being performed around manufacturing areas, have supervision and personnel in that area been notified?	☐	☐
C. SUPPLEMENTAL DOCUMENTS - Are any of the following required to perform task? (check all that apply) ☐ Hot Work Cutting/Welding Permit ☐ Odorous Activity Notification ☐ Energized Electrical Permit ☐ Crane and Hoist Lift Plan (General, Critical) ☐ Decontamination and Materials Movement Checklist (orange tag) ☐ Safety Data Sheet(s) ☐ Other: __________ ☐ Excavation Permit ☐ Confined Space, Permit ☐ Confined Space, Reclassification ☐ Fall Prevention Plan / Rescue Plan (Working From Heights) ☐ Lockout/Tagout Procedure or Tagout Only Procedure ☐Impairment Form (Fire, Life Safety)
D. PPE (Personal Protective Equipment) - Are any of the following PPE required to perform task? (Use menu below to select applicable PPE) Eye Protection:__________ Face Protection:__________ Hand protection:__________ Head Protection: __________ Body Protection:__________ Hearing Protection:__________ Foot Protection:__________ Respiratory Protection:__________ Other: __________
E. EMERGENCY INFORMATION (from the work area):
Location (stairwell #, column #, grid line #, equipment ID, etc.)	Emergency Contact Information
Muster Point / Shelter in Place	__________	TI Site Emergency Phone	Phone: __________
Nearest Exit	__________	Supplier On-site Emergency Contact	Name:__________ Phone: __________
Nearest Phone	__________	Supplier Company Emergency Contact	Name: __________ Phone: __________
Fire Extinguisher	__________	Supplier Medical Provider (optional)	Name: __________
Eye Wash/ Shower	__________	Other	__________

Immediately report near misses to your supervisor and/or project manager.

Immediately call TI Site Emergency Phone and your supervisor and/or project manager for injury, illness or facility events.

Permit #:
F. JOB TASK and HAZARD ANALYSIS FORM
Examine each step in the job task, identify the potential hazards and determine the measures to protect personnel from these hazards. This is accomplished by 1) listing all the steps required to complete the job, 2) evaluating each step for potential hazards, and 3) recording the precautions required for completing the task safely. Be specific in your comments remembering to engineer the hazard out when possible and only resort to providing protective equipment when it is not possible to remove the hazard. Specifically list personal protective equipment when it is required. Do not use general statement.
Step #	Sequence of Basic Job Steps	Safety + Reliability Hazards	Safety + Reliability Controls
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Permit #:
G. GENERAL ACKNOWLEDGEMENT Signature of Supervisor indicates completion of following activities: Work area has been walked by field service personnel to identify safety and/or impact concerns. Area is safe to work in (i.e. housekeeping, guarding, congestion, work surfaces, access). Work has been coordinated with other crews in the area. All tools and equipment are safe and in good condition (includes assured grounding, slings, hand tools, etc.) All necessary training for this task has been completed. All necessary Personal Protective Equipment is available at the job site in proper working condition All new employees have been familiarized with work area. Sufficient personnel have been assigned to complete this task safely. Emergency exits and equipment have been identified (phones, fire extinguishers, eyewashes, etc.). Area has been designated and protected from passersby by cones, safety tapes, barricades, or other means. In addition to items 1 through 10 above, Supplier Supervisor signature also indicates completion of following activities: Contingency plans have been developed for unexpected events (medical emergency and/or equipment failure, Evacuation Employee Roster). Site specific hazard information pertaining to this job has been evaluated by Supplier. Note to Supplier: By administering this worksheet, Supplier understands that it is responsible for training and PPE obligations for its employees and that Texas Instruments is in no way undertaking any training responsibilities nor is it warranting to the supplier’s workforce, to its subcontractors, to any governmental agency, or to the general public, that the contractor’s pre-task planning fulfills any duties or responsibilities owed to these individuals. This worksheet is administered solely as a “tool” to integrate contractors’ Job Hazard Analysis into the work permit process and to screen out those contractors that pose an apparent threat to the safety of Texas Instruments employees by not having any process for pre-task planning.
Participated, Read, Understood and Agreed Prior to Start of Work	DATE	DATE	DATE	DATE	DATE	DATE
Initial daily BEFORE work begins
Supervisor	(Printed name and Signature)
Member/Worker	(Printed name and Signature)
Member/Worker	(Printed name and Signature)
Member/Worker	(Printed name and Signature)
Member/Worker	(Printed name and Signature)
Member/Worker	(Printed name and Signature)
Member/Worker	(Printed name and Signature)
Member/Worker	(Printed name and Signature)
IF WORK SCOPE OR CONDITIONS / ACTIVITIES CHANGE THAT COULD IMPACT SAFETY OR RELIABILITY, WORK MUST STOP UNTIL PLAN IS REVISED AND REVIEWED BY TI PROJECT MANAGER AND ESH (AND RELIABILITY CHAMPION, WHERE REQUIRED).
Person Completing JHA Form	(Signature required one time) Printed name, signature, date