Title Page
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Daily Work Summary
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What type(s) of work are being performed today? Select all that apply.
- General
- Demolition
- Electrical
- Cleanup
- OTHER
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Site / Project Name
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Primary Evacuation Zone
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Wind Direction
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Describe the works to be undertaken today
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Have all crew members performed daily stretch and flex activities?
Today's Task Breakdown
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Break today's work into individual step-by-step-tasks below. Assess each task for hazards and controls
Work Task
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Describe this task
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Tools and Equipment to be used
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What category does this task fall under?
- General
- Demolition
- Electrical
- Cleanup
- OTHER
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Select potential hazards that may be encountered while completing this task today.
- Fall / Gravity
- Equipment Issues
- Power Lines
- Electricity
- Sharp Objects
- Slippery / Wet Surfaces
- Gasses
- Dust
- Underground Utilities
- Overhead Obstructions
- Hazardous Substances
- Working In Isolation
- Ignition Sources
- Manual Handling
- High Pressure Lifting Equipment
- Rotating Machinery
- Entry & Exit Hazards
- Ground Openings
- Entanglement
- Animals / Pests
- High Voltage
- Confined Space
- Adverse Weather Conditions
- Pollution
- Grinding
- Hazards to Public Areas
- Hazardous Chemicals
- Extreme Temperature
- Noise
- Radiation
- Biological
- Social / Interpersonal
- Staffing Issues
- Project Delay
- OTHER
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Describe the other potential hazards that may be encountered while completing this task today.
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What categories of hazard control will you apply to this task?
- Elimination - Remove the hazard
- Substitution - Replace the hazard
- Engineering - Isolate people from the hazard
- Administrative - Change the way people work
- PPE - Protect workers with personal protective equipment
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What specific controls will you apply to the above hazards for this task?
- Training
- Replacement
- Removal
- Repair
- Spotters
- Lighting
- Isolation
- Respiratory Protection
- Application of PPE
- Signage
- Barricades
- Fall Arrest
- Extinguishers
- Screens
- Additional Resources
- Fire Blankets
- Updated Procedures
- Competent Persons
- Locating Equipment
- UV Protection
- Gas Detection
- Designated Work Areas
- Supervision of Public
- Elevation to Senior Management
- OTHER
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Describe any other specific controls will you apply to the above hazards for this task.
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(LOTO) Procedure required for task?
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LOTO Plan reviewed with crew?
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Any other permits required?
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Permit type.
Final Checks
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Does every member of the on-duty crew have adequate and appropriate PPE for today's work tasks?
Crew Sign Off
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Each present team member to sign name and signature acknowledging the above tasks, hazards and controls.
Team Member
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I HAVE READ AND UNDERSTAND THE JOB SAFETY ANALYSIS AND PERMITS AND AGREE TO ADHERE TO ALL SAFETY PRECAUTIONS AND PROCEDURES TO COMPLETE THIS JOB SAFELY. IF ANY PART OF MY TASSK PLAN CHANGES OR NEW HAZARDS EXIST, I WILL ALERT MY FOREMAN AND OPERATIONS AND MODIFY THE JSA.
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Name & Signature