JOB SAFETY ANALYSIS (JSA) FORM - duplicate

• Job Safety Analysis

• Principal

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Site information

• Job name

• Task activity

• Date

  Date

• PO number

• Sub Contractor

Potential hazards

• OSHA & Emergency posters posted

  Yes

  No

  N/A

• Mobile heavy equipment activity

  Safe

  At Risk

  N/A

• Work affecting integrity of critical controls

• Activities in or near traffic areas

  Safe

  At Risk

  N/A

PPE ( minimum requirement: safety boots, hard hat, vis vest, glasses, gloves)

• Eye protection

  Yes

  No

  N/A

• Hearing protection

  Yes

  No

  N/A

• Dust protection

  Yes

  No

  N/A

• Gloves

  Yes

  No

  N/A

• Other (fire retardant coveralls, breathing apparatus, etc) specify :

• Working at heights above 6ft

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Fall protection application used

Barricades

• Floor openings planked over or barricaded

  Yes

  No

  N/A

• Controlled access zone

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Type of CAZ and location

Scaffolding

• Inspection of scaffolding. (guard rails, toe boards, mid rails, etc.

  Yes

  No

  N/A

• Properly tagged

  Yes

  No

  N/A

• Permission granted

  Yes

  No

  N/A

Stairs

• Inspection of stairs to include lighting, handrail ,fall protection , permission

  Yes

  No

  N/A

Ladders

• Inspection of ladders

  Yes

  No

  N/A

Housekeeping & sanitation

• Condition of site / work area

  Yes

  No

  N/A