Information
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Audit Title
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Document No.
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Conducted on
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Prepared by
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Location
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Job Site Supervisor
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TASK DESCRIPTION:
LOCATION
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Subdivision
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Subdivision Name
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Muster Point
HAZARDS
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Start date
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End Date
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1.1. Heights
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1.2. Equipment
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1.3. Power Lines
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1.4. Electricity
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1.5. Sharp Objects
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1.6. Slippery / Wet Surfaces
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1.7. Gasses
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1.8. Dust
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1.9. Underground Utilities
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1.10. Overhead Obstructions
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1.11. Hazardous Substances
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1.12. Working Alone
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1.13. Ignition Sources
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1.14. Manual Handling
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1.15. Lifting Equipment
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1.16. Access and Egress
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1.17. Ground Openings
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1.18. High Voltage
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1.19. Confined Space
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1.20. Sun Rays / Adverse Weather Conditions
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1.21. Pollution
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1.22. Grinding
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1.23. Public Areas
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1.24. Other Hazards
CONTROL MEASURES
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2.1. Isolations<br>
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2.2. Spotters
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2.3. Lighting
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2.4. Respiratory Protection
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2.5. Application of PPE
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2.6. Signage
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2.7. Barricades
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2.8. Fall Arrest
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2.8. Extinguishers
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2.9. Screens
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2.10. Fire Blankets
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2.11. Procedures
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2.12. Competent People
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2.13. Locating Equipment
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2.14. UV Protection
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2.15. Gas Detection
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2.16. Designated Work Areas
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2.17. Safety of Public
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2.18. Other Control Measures
DESCRIPTION OF WORKS & CONTROLS
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3.1. Job Steps
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3.2. Risk Description
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3.3. Controls Description
PPE
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Was all PPE inspected?
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List all PPE need to before these tasks
INCIDENTS
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Were there any incidents or injuries on your shift? If yes explain incident and date and time.
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If yes to incident or injury please explain below in detail including date of incident.
dates site inspected
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Select date
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SIGN OFF
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Employee
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Employee
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Employee
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Employee
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Site Supervisor
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Authorized Person: I have reviewed this JSA and agree that it is a fair assessment of the job and I authorize this work to proceed.
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Site Supervisor
