Job Safety Analysis (JSA)

• Site conducted

  Select

• JOB #:

• Date:

  Date

• Customer:

• Weather Condition/Heat Index:

• Description of TASK:

• Specific Location of TASK:
  Address

• Competent Person (If required):

• Safety Topic Discussed

• INSTRUCTIONS
  
  1. Please answer "Yes", "No" or "N/A" on the questions below.
  2. Some items will require a ✔ or ✖ answer.
  3. Add Photos in "Images" and Comments in "Notes" on each question.
  4. Add a Corrective Measure in "Action." Provide a description, assign to a member, set priority, and due date
  5. Complete the audit by providing a digital signature
  6. Share your report by exporting as PDF, Word, Excel or Web Link.

• Number of Workers Attending JSEA:

• Supervisor/Foreman Signature:

  Sign

WORK AREA EVALUATION

• Are any permits required for this task?

  Yes

  No

  N/A

• Has this task been coordinated with other trades?

  Yes

  No

  N/A

• Are ground conditions adequate for construction activities?

  Yes

  No

  N/A

• Are you working around power lines, pipelines or other utilities?

  Yes

  No

  N/A

• Are fire extinguishers nearby, inspected and fully charged?

  Yes

  No

  N/A

• Do you have the PPE needed for this task?

  Yes

  No

  N/A

• Are you familiar with evacuations routes?

  Yes

  No

  N/A

• Does this task require special training?

  Yes

  No

  N/A

• Is an SDS review necessary for this task?

  Yes

  No

  N/A

• Does this task involve a confined space?

  Yes

  No

  N/A

• Is air monitoring required?

  Yes

  No

  N/A

• Have all tools/equipment been inspected prior to use?

  Yes

  No

  N/A

• Damaged tools/equipment tagged & removed from site?

  Yes

  No

  N/A

• Are the required materials and tools provided?

  Yes

  No

  N/A

• List any safety issues that have not been addressed by this evaluation.

POTENTIAL HAZARD CHECKLIST (check all hazards that apply)

• Potential Hazards- select all that apply

  Select Excavations Crushing/Cave-In Pinch Point Thermal Burns Particles in Eye Housekeeping Chemical Burns Man Overboard/Drowning Inadequate Access High Noise Area/Levels Falling Objects Elevated Work Manual Lifting Chemical or Fuel Spill Ladders Electrical Wall/Floor Openings Hazardous Chemicals Heat Exhaustion/Stress Sharp Objects/Tools Lockout/Tagout Critical Lift Rigging Slip/Trip Confined Space Fire/Hot Work Scaffolding Falls from Elevation Power Tools New Workers to Site Air Quality

  • Excavations
  • Crushing/Cave-In
  • Pinch Point
  • Thermal Burns
  • Particles in Eye
  • Housekeeping
  • Chemical Burns
  • Man Overboard/Drowning
  • Inadequate Access
  • High Noise Area/Levels
  • Falling Objects
  • Elevated Work
  • Manual Lifting
  • Chemical or Fuel Spill
  • Ladders
  • Electrical
  • Wall/Floor Openings
  • Hazardous Chemicals
  • Heat Exhaustion/Stress
  • Sharp Objects/Tools
  • Lockout/Tagout
  • Critical Lift
  • Rigging
  • Slip/Trip
  • Confined Space
  • Fire/Hot Work
  • Scaffolding
  • Falls from Elevation
  • Power Tools
  • New Workers to Site
  • Air Quality

• Other Hazards

  NO

  YES

PPE that’s required:

• Required PPE- select all that apply

  Select Hard Hat Safety Glasses Hi-Vis Clothing / Vest Appropriate Gloves Hearing Protection Work Boots Steel Toe Personal Flotation Device Dust Mask Respirator Fire Retardant Clothing Fall Harness Face Shield Welding Shield Torch Goggles

  • Hard Hat
  • Safety Glasses
  • Hi-Vis Clothing / Vest
  • Appropriate Gloves
  • Hearing Protection
  • Work Boots Steel Toe
  • Personal Flotation Device
  • Dust Mask
  • Respirator
  • Fire Retardant Clothing
  • Fall Harness
  • Face Shield
  • Welding Shield
  • Torch Goggles

• Other

ADD DESCRIPTION / STEPS OF TASK LISTED ABOVE

• DESCRIPTION / STEPS OF TASK LISTED ABOVE ((WHAT AM I DOING))

• HAZARDS ASSOCIATED WITH EACH STEP OF TASK (WHAT WILL HURT ME)

• REQUIRED ACTIONS TO ELIMINATE OR CONTROL THE HAZARDS (HOW WILL I KEEP WHAT I AM DOING FROM HURTING ME)

• All employees have the right and responsibility to stop any unsafe job or activity. Employees are responsible for immediately reporting any workplace incident to their supervisor

*NUMBER OF WORKERS SIGNATURES MUST MATCH NUMBER OF WORKERS LISTED ON PAGE ONE*

• **SIGNATURE OF ALL EMPLOYEES ASSOCIATED WITH THIS TASK SHALL BE ON THIS JSEA**

Add worker's name.

• Name & Signature:

  Sign