B.W. JSA

• Project No.

• Project Name.

• Conducted on

  Date

• Prepared by

Traffic management

• Estimated traffic volume (cars & trucks)

• Permanent traffic speed through area

• Risk rating

  High

  Low

• Workman Ahead Signs

• Road Work Ahead Signs

• Flashing Lights on Vechile

• Spotter / Lookout Person

• Vehicle parked between oncoming traffic and work site

• Other

Site Hazards

• Electrical Assets

  Yes

  No

  N/A

• Control Measures Taken

• Overhead Powerlines<br>

  Yes

  No

  N/A

• Control Measures Taken

• Rail / Tram Tracks

  Yes

  No

  N/A

• Control Measures Taken

• Machinery / Heavy Plant

  Yes

  No

  N/A

• Control Measures Taken

• Confined Spaces

  Yes

  No

  N/A

• Control Measures Taken

• Trenches / Excavations

  Yes

  No

  N/A

• Control Measures Taken

• Watercourses

  Yes

  No

  N/A

• Control Measures Taken

• Uneven surfaces / disorderly worksites

  Yes

  No

  N/A

• Control Measures Taken

• Fencing

  Yes

  No

  N/A

• Electric

• Barbwire

• Other

• Control Measures Taken

• Animals (eg. Dogs, snakes, cattle) Detail:

  Yes

  No

  N/A

• Control Measures Taken

• Noise

  Yes

  No

  N/A

• Control Measures Taken

• Working underneath structures / Overhead works in progress

  Yes

  No

  N/A

• Control Measures Taken

• Extreme Temperatures:

  Yes

  No

  N/A

• Heat

• Cold

• Control Measures Taken

• UV Radiation

  Yes

  No

  N/A

• Control Measures Taken

• Fatigue

  Yes

  No

  N/A

• Control Measures Taken

• Night Works

  Yes

  No

  N/A

• Control Measures Taken

• Manual Handling (eg. Lifting drainage pits, carrying stations)

  Yes

  No

  N/A

• Control Measures Taken

• Remote Work / One Person

  Yes

  No

  N/A

• Control Measures Taken

List any additional identified hazards:

Hazard:

Clearly Print Name:

• Have all members of the work party reviewed the Daily JSA and understand their role in the safe completion of the work:

  Yes

  No

  N/A
Name:

• Add signature

  Sign