JOB SAFETY ANALYSIS (JSA) FORM

• Site conducted

  Select

• Client / Site

• Job Number

• Project Manager

  Select

• Prepared by

  Select

• Conducted on

  Date
• Job Location
  Address

All of the crew members shall sign below at start of shift

Personnel/Crew Member

• Name & Signature

  Sign

General Task

• General Description of the Task

Task Activity (List all basic job steps)

• 1st Step

• 2nd Step

• 3rd Step

• 4th Step

• 5th Step

Check Applicable Anticipated or Potential Hazards (Do Not Limit Hazards to List Only)

• Electrocutions/Shock/Arc

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Overhead Work

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Rough/Sharp Material

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Slippery/Uneven Surfaces

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Rotating/Moving Machinery

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Hot Surfaces

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Pinch/Crush/Nip Points

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Flying Particles

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Activities in or near traffic areas

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Poor Work Positions/Access

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Noise

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Flammable Material/Fire

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Underground Utilities

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Falling Objects & Debris

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Obstructed Vision

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Power Lines

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Concrete cutting or coring

  Safe

  At Risk

• What corrective actions did we take to reduce or eliminate the risk?

• Other (specify) :

  Yes

  No

• What corrective actions did we take to reduce or eliminate the risk?

Critical Procedures: where work involves any of the following hazards must be incorporated into JSA

• Confined space entry (includes tank cleaning)

  Yes

  No

• Heavy equipment lifting (riggers lift, cranes, boom trucks, excavators)

  Yes

  No

• Critical Lifts: Lift that exceeds 75 percent of rated capacity, Requires the use of one or more crane, Lifting Personnel

  Yes

  No

• Lockout/Tagout (Electrical, Pneumatic, Hydraulic, Mechanical, Gravity, Chemical, Etc.)

  Yes

  No

• What power sources are locked out?

  Select Electrical Pneumatic Hydrualic Mechanical Gravity Chemical Thermal Steam Magnetic Radiation

  • Electrical
  • Pneumatic
  • Hydrualic
  • Mechanical
  • Gravity
  • Chemical
  • Thermal
  • Steam
  • Magnetic
  • Radiation

• Work at heights above 6 ft. (4 ft. for General Industry)

  Yes

  No

• Respiratory Protection

  Yes

  No

• Entry into excavations/Trenches > 1.2 m (4ft) deep

  Yes

  No

• Hot work (in potentially explosive atmosphere)

  Yes

  No

Tools / Equipment

• The proper tools and equipment are onsite for the job

  Yes

  No

PPE (minimum requirement: steel toe boots, hard hat, visi-vest, glasses, gloves)

• What PPE is needed for this job?

  Select Fall Protection Hearing Protection Respiratory Protection Face Shield Welding Shield

  • Fall Protection
  • Hearing Protection
  • Respiratory Protection
  • Face Shield
  • Welding Shield

Mid Day Review with Crew

• Is there any new tasks added or changed to today's activities?

  Yes

  No

• What was/is the change in task and what safety measures were put in place?

Mid Day Review Signature

• All crew members shall sign below confirming that a mid day review has been conducted and any changes in the task is understood and noted on JSA.

• Date

  Date
Personnel/Crew Member

• Name & Signature

  Sign

AME COVID-19 Protocols

• Are there any new or preexisting case of COVID-19 onsite?

  Safe

  At Risk

  N/A

• Customer's Signature

  Sign

Supervisor/Foreman

• Are all lock & tags removed?

  Yes

  No

• Area cleaned/Secured & tools stored?

  Yes

  No

• Did any injuries occur?

  Yes

  No

• Who was injured?

• Did you report this injury?

  Yes

  No