DPI Job Safety Analysis

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

site information

• work order number

• task activity

• date

  Date

• Site number/Name

check applicable anticipated or potential hazards

• Equipment Removal

  Safe

  At Risk

  N/A

• Cabling Ceiling, Walls and Flooring

  Safe

  At Risk

  N/A

• Rough in Mechanicals

  Safe

  At Risk

  N/A

• Bracket Fit Off

  Safe

  At Risk

  N/A

• Cable Terminations

  Safe

  At Risk

  N/A

• Equipment Fit Off

  Safe

  At Risk

  N/A

• Programming

  Safe

  At Risk

  N/A

• Commissioning

  Safe

  At Risk

  N/A

• Other (specify) :

  Safe

  At Risk

  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

  Yes

  No

  N/A

• Heavy Mechanical Fit Off

  Yes

  No

  N/A

• Heavy Lifting

  Yes

  No

  N/A

ensure all hazards identified are addressed in JSA below

• 1. sequence of basic job Step in order

• 1.potential hazards.

• 1.safety controls to reduce or eliminate hazard

• 2. sequence of basic job Step in order

• 2. potential hazards.

• 2. safety controls to reduce or eliminate hazard

• 3. sequence of basic job Step in order

• 3. potential hazards.

• 3.safety controls to reduce or eliminate hazard

• 4. sequence of basic job Step in order

• 4. potential hazards.

• 4.safety controls to reduce or eliminate hazard

• 5. sequence of basic job Step in order

• 5. potential hazards.

• 5.safety controls to reduce or eliminate hazard

Tools / Equipment ( list of tools and equipment 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

• Hand Protection

  Yes

  No

  N/A

• Dust Protection

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

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

Outside Authorities

• Name/Title

• Signature

  Sign

DPI Staff Signatures

Staff Sign Off

• Add signature

  Sign

• date

  Date

Site Contact Signature

• JSA approved signature

  Sign

• date

  Date