Title Page
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Document No.
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Audit Title
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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
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Does the JSA identify appropriate PPE?
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Has a work site assessment been completed?
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Does the JSA list all activity and reference documents for the day?
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Does the JSA identify appropriate job steps, potential hazards and mitigation steps?
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Have all effected employees and visitors involved in the operational job task signed the JSA?
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Did all involved discuss the hazardous areas associated with the operation, with mitigation steps to follow?
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Did the employee sharing the JSA information ensure you the appropriate PPE to visit the location?
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Did the employee sharing the JSA request you repeat the hazards and mitigation steps back to you?
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Were the identified referenced documents available for review?
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Were employees working according with the documented work task and activity?
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If a critical activity is identified, has the supervisor been notified?
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Did management or the supervisor use positive reinforcement for safe behavior observed?
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Were employees effectively communicating with all involved while performing the job task?
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Contractor Employee Name / Signature:
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Auditor Name:
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Select date
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