I7G JOB SAFETY ANALYSIS

• Date/Time Issued

  Date
• Location
  Address

• Prepared by

• Client Name

• Site Name

• Address

• Nearest Medical Facility

• Address

• Phone

• List the key tasks required to complete the project.

Task

• Task

HAZARDS

• Driving/Traffic

  Safe

  At Risk

  N/A

• Moving Equipment

  Safe

  At Risk

  N/A

• Walking/Working Surfaces

  Safe

  At Risk

  N/A

• Hand/Power Tools

  Safe

  At Risk

  N/A

• Sharp Edges/Cuts

  Safe

  At Risk

  N/A

• Noise

  Safe

  At Risk

  N/A

• Overhead Hazards

  Safe

  At Risk

  N/A

• Falling Objects

  Safe

  At Risk

  N/A

• Working at Heights

  Safe

  At Risk

  N/A

• Vibration

  Safe

  At Risk

  N/A

• Utilities

  Safe

  At Risk

  N/A

• Type

  Select

• Confined Space Entry

  Safe

  At Risk

  N/A

• Type

  Select

• Ergonomic

  Safe

  At Risk

  N/A

• Type

  Select

• Biological

  Safe

  At Risk

  N/A

• Type

  Select

• Energy

  Select Safe At Risk N/A

  • Safe
  • At Risk
  • N/A

• Type

  Select

• Chemical

  Select Safe At Risk N/A

  • Safe
  • At Risk
  • N/A

• Type

  Select

• Weather

  Safe

  At Risk

  N/A

• Type

  Select

ENGINEERING/ADMINISTRATIVE

• Pre-Trip Inspection

  Yes

  No

  N/A

• Safe Driving Practices

  Yes

  No

  N/A

• Follow Established SOPs

  Yes

  No

  N/A

• Lock-Out/Tag-out Procedures

  Yes

  No

  N/A

• Confined Space Entry Procedures

  Yes

  No

  N/A

• Ventilation

  Yes

  No

  N/A

• Housekeeping

  Yes

  No

  N/A

• Verify Utility Locates

  Yes

  No

  N/A

• Distance to Overhead Wires

  Yes

  No

  N/A

• Caution/Danger Tape

  Yes

  No

  N/A

• Barrier Cream/Sunscreen

  Yes

  No

  N/A

• Insect Repellent

  Yes

  No

  N/A

• Moisture

  Yes

  No

  N/A

• Glove Bag/Enclosure

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Description

PERSONAL PROTECTIVE EQUIPMENT

• Head

  No

  Yes

  N/A

• Type

  Select

• Body

  Select No Yes N/A

  • No
  • Yes
  • N/A

• Type

  Select

• Hand

  No

  Yes

  N/A

• Type

  Select

• Footwear

  No

  Yes

  N/A

• Type

  Select

• Eye/Face Protection

  No

  Yes

  N/A

• Type

  Select

• Hearing Protection

  No

  Yes

  N/A

• Type

  Select

• Respiratory Protection

  No

  Yes

  N/A

• Type

  Select

• Fall Protection

  No

  Yes

  N/A

• Type

  Select

TOOLS & EQUIPMENT

• Atmospheric Monitoring

  Yes

  No

  N/A

• Fresh air zero before use

• Energy Isolation (LOTO)

  Yes

  No

  N/A

• Confirm isolation before beginning work

• Retrieval Equipment (Winch/Tripod)

  Yes

  No

  N/A

• Inspect before use

• Lifeline: Rope/SRL

  Yes

  No

  N/A

• Inspect before use

• Fall Protection Equipment

  Yes

  No

  N/A

• Inspect before use

• Ladder

  Yes

  No

  N/A

• Inspect before use

• Hand Tools

  Yes

  No

  N/A

• Lighting

  Yes

  No

  N/A

• GFCI

  Yes

  No

  N/A

• Ventilation Equipment

  Yes

  No

  N/A

• Grounding/Bonding

  Yes

  No

  N/A

• Non-Sparking Tools

  Yes

  No

  N/A

• Explosion-Proof Lighting

  Yes

  No

  N/A

COMMUNICATION

• Method(s)

  Select Voice Air Horn Radio Cell Phone Other

  • Voice
  • Air Horn
  • Radio
  • Cell Phone
  • Other

• We reviewed the work authorized by this permit and the information it contains. We received safe work procedures and understand the hazards present in this area. This assessment is not complete unless all appropriate sections are reviewed. We understand to immediately report any close calls, injuries, equipment/property damage, or environmental releases to the project manager.

TEAM MEMBERS

• Name

  Sign

• Were you injured today?

  No

  Yes

  N/A

CONFINED SPACE ENTRY DETAILS

• Name of Space

• Entry Purpose

• Monitor ID

• Monitoring Type

  Continuous

  Intermittent

• Entry Supervisor

• Attendant

• Authorized Entrant(s)

• Rescue Service

• Rescue Phone

ENTRY LOG

• Time

  Date

• O2 (19.5% - 23.5%)

• LEL (<10%)

• CO (<35 PPM)

• H2S (<10 PPM)

• Attendant

• Entrant(s)

PERMIT CANCELLED

• Select date

  Date