Branch 23 JOB SAFETY ANALYSIS (JSA) FORM

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

site information

• Job & Dept.

• Title of person who does job:

• Dept. Supervisor

• date

  Date

check applicable anticipated or potential hazards

• Exposure to chemicals?

  Safe

  At Risk

  N/A

• Activities in or near high traffic areas

  Safe

  At Risk

  N/A

• Powered Industrial Truck equipment activity (Forklifts, Pallet Jacks, Reach trucks, Die Carts, Walk-Behinds)

  Safe

  At Risk

  N/A

• Work affecting integrity of critical controls

  Safe

  At Risk

  N/A

• Welding, cutting, grinding

  Yes

  No

  N/A

• Arch flash hazards

  Yes

  No

  N/A

• pressure testing

  Yes

  No

  N/A

• Other (specify) :

  Yes

  No

  N/A

critical procedures: where work involves any of the following hazards must be incorporated into JSA

• Work at heights above 1.5m

  Yes

  No

  N/A

• Confined space entry (includes tank cleaning)

  Yes

  No

  N/A

• Electrical/Mechanical lockout (live, isolation, lock out / tag out

  Yes

  No

  N/A

• Heavy equiptment lifting (cranes, boom trucks, excavators)

  Yes

  No

  N/A

• Hot work (in potentially explosive atmosphere)

  Yes

  No

  N/A

ensure all hazards identified are addressed in JSA below

• 1. sequence of basic job Step in order

• 1.potential hazards. (Ex. underground services, hazard zone etc.)

• 1.safety controls to reduce or eliminate hazard

• 2. sequence of basic job Step in order

• 2. potential hazards. (Ex. underground services, hazard zone etc.)

• 2. safety controls to reduce or eliminate hazard

• 3. sequence of basic job Step in order

• 3. potential hazards. (Ex. underground services, hazard zone etc.)

• 3.safety controls to reduce or eliminate hazard

• 4. sequence of basic job Step in order

• 4. potential hazards. (Ex. underground services, hazard zone etc.)

• 4.safety controls to reduce or eliminate hazard

• 5. sequence of basic job Step in order

• 5. potential hazards. (Ex. underground services, hazard zone etc.)

• 5.safety controls to reduce or eliminate hazard

• 6. sequence of basic job Step in order

• 6. potential hazards. (Ex. underground services, hazard zone etc.)

• 6.safety controls to reduce or eliminate hazard

• 7. sequence of basic job Step in order

• 7. potential hazards. (Ex. underground services, hazard zone etc.)

• 7.safety controls to reduce or eliminate hazard

• 8. Sequences of basic job Step in order

• 8. potential hazards. (Ex. underground services, hazard zone etc.)

• 8.safety controls to reduce or eliminate hazard

• 9. Sequences of basic job Step in order

• 9. potential hazards. (Ex. underground services, hazard zone etc.)

• 9 . safety controls to reduce or eliminate hazard

tools / Equipment ( list of tools and equipment and their storage on site, if relevant to safety

• List

  Yes

  No

  N/A

additional PPE ( minimum requirement: safety boots, hard hat, visi-vest, glasses, gloves)

• Eye protection

  Yes

  No

  N/A

• Hearing protection

  Yes

  No

  N/A

• Fall protection

  Yes

  No

  N/A

• Cotton gloves

  Yes

  No

  N/A

• Chemical resistant gloves

  Yes

  No

  N/A

• Splash goggles

  Yes

  No

  N/A

• Chemical resistant apron

  Yes

  No

  N/A

• Hard hat

  Yes

  No

  N/A

• Dust respirator (N95)

  Yes

  No

  N/A

• Full face respirator

  Yes

  No

  N/A

• Face shield

  Yes

  No

  N/A

• Vapor respirator

  Yes

  No

  N/A

• Chemical resistant boots

  Yes

  No

  N/A

• Chemical resistant body suit

  Yes

  No

  N/A

• Leather gloves

  Yes

  No

  N/A

• Portable gas monitor

  Yes

  No

  N/A

• Other (fire retardant coveralls, breathing apparatus, etc) specify :

site supervisor

• Approved by:

  Sign

• date

  Date