Daily JSA

• Conducted on

  Date

• Client

• Project Name

• Superintendent

• Prepared by

• Location
  Address

• Have you walked work area?

  Yes

  No

  N/A

• Are all Personnel wearing PPE? I.E Hard hat, Safety Glasses, Gloves, ANSI 2 Vest

  Yes

  No

  N/A

• Has the Work Area of Other Trades been Identified?

  Yes

  No

  N/A

• Is the SDS necessary for the Task?

  Yes

  No

  N/A

• Are any work permits necessary? If so please attach any Site Specific Permits

  Yes

  No

  N/A

• Based on Scope of Work, Complexity, and Hazards; Is a Site Specific Plan Required?

  Yes

  No

  N/A

• Is a Safety Professional required on Site?

  Yes

  No

  N/A

• Has a Evacuation Route been Established?

  Yes

  No

  N/A

Equipment Inspection

• Is all Emergency Equipment up to Date? I.E. Eyewash Station, First Aid Cabinet

  Yes

  No

  N/A

• Have all Power Tool and Extensions been inspected?

  Yes

  No

  N/A

• Have all rigging and lifting equipment been inspected?

  Yes

  No

  N/A

• Are there Fire Extinguishers within 25 feet or all generators and Fuel Storage?

  Yes

  No

  N/A

Potential Hazards

• Impact Hazards

  Yes

  No

  N/A

• Penetration/Puncture Hazards

  Yes

  No

  N/A

• Cold Temperature Exposure

  Yes

  No

  N/A

• Heat Exhaustion/Heat Stroke

  Yes

  No

  N/A

• Fire Hazard

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

• Heavy Lifting Potential

  Yes

  No

  N/A

• Anhydrous Ammonia Exposure

  Yes

  No

  N/A

• Hydrogen Sulfide Exposure(Landfill Gas)

  Yes

  No

  N/A

• Mobile Equipment(ATV)

  Yes

  No

  N/A

• Knife Cuts and Punctures

  Yes

  No

  N/A

• High Noise Levels

  Yes

  No

  N/A

• Ice, Mud, High Winds

  Yes

  No

  N/A

• Confined Space Permit

  Yes

  No

  N/A

Tasks

• Scope of Work

• Hazards Associated with Task

• Required Actions to Mitigate Hazards

Mobile Equipment & Heavy Equipment

• Excavator

  Sign

• Skidsteer

  Sign

• UTV

  Sign

• Forklift

  Sign

• Qualified Rigger

  Sign

Task

• Liner

• Geocomposite

• GCL

• Raincover

• Wind Defender

• Rope and Sand Bag Ballast

• Agruturf

• Liner Foreman | Dan Rodriguez

  Sign

Crew

• Bryan Lagunas

  Sign

• Crecensio Velasquez

  Sign

• Bertoldo Gutierrez

  Sign

• Dan Rodriguez

  Sign

• Jesus Nunfio Lopez

  Sign

• Jesus Lopez

  Sign