Information

  • Document No.

  • Name

  • Conducted on

  • Job location

  • Job description

  • Personnel involved in task

  • If more than one person involved in task - STOP and do a JSA

Checklist

  • 1. Can I be injured by being caught in, on or between anything?<br>Pinch points, rotating machinery, conveyors, caught between vehicles or machinery, roof and rib conditions.

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 2. Can I strain or overexert myself?<br>Does the task require repetitive movement, pushing, pulling, lifting, awkward postures, sustained postures?

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 3. Can I fall onto, into or from anything?<br>Working above 1.8m, fall onto sharp objects, fall from machinery

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 4. Can I slip or trip on anything?<br>Tools / Equipment, wet / slippery surfaces, poor housekeeping, uneven surfaces

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 5. Can I be struck by a moving object?<br>Moving vehicles, projectiles, moving machinery

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 6. Can I come into contact with or be exposed to something that may harm me? (E.g. electricity, gas, heat, acid, grease, hazardous substances or stored energy.)

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 7. Does anything need to be isolated and tested for dead?<br>Electrical, water, hydraulic, high pressure

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 8. Can something fall on me or can I cause something to fall onto someone else?<br>Falling tools / equipment

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 9. Can I be injured by nearby activities or can my activities injure others nearby?<br>People working above / below me, dust or fumes, noise, sparks, projectiles

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 10. Could there be any uncontrolled movement, like ground movement, machine movement?<br>Ground failure, high wall / low wall failure, roof / rib failure, runaway vehicle

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 11. Can I spill or pollute anything?<br>Oil spill, release into waterways, pitwater release

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 12. Can weather conditions, work environment or poor lighting affect job safety?<br>Extreme temperatures, lack of lighting, fog storm

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 13. Do I need a sub-permit?<br>Hot work, confined space, working at heights, asbestos, radiation, drilling, cutting and excavating near concealed services

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A sub-permit is required for this task.

  • 14. Will I be working below, on or near a highwall or crest?<br>Within 5m of the crest, 10m of the toe of a <60m continuous highwall slope or 15m of the toe of a >60m continuous highwall slope in an open pit.

  • Refer to Site Geotechnical Guidelines

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

  • 15. Are there any other hazards present?

  • Can I manage this hazard?

  • List controls put in place to manage this hazard

  • Will controls effectively manage the hazard?

  • STOP the job and contact your Supervisor. A JSA is required for this task.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.