Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

site information

  • work order number

  • task activity

  • date

  • Site number/Name

  • name of contractor/Subcontractor

check applicable anticipated or potential hazards

  • Demolition

  • Underground tank removal/Disposable/High vapors

  • Activities in or near traffic areas

  • Concrete cutting or coring

  • Mobile heavy equipment activity (excavators, dump trucks, vacuum and hydovac trucks)

  • Pile driving / shoring

  • Work affecting integrity of critical controls

  • Welding, cutting, grinding

  • Hydoblasting / sand blasting

  • Radiography / X-Ray testing

  • pressure testing

  • Other (specify) :

critical procedures: where work involves any of the following hazards must be incorporated into JSA

  • Work at heights above 1.5m

  • Confined space entry (includes tank cleaning)

  • Electrical/Mechanical lockout (live, isolation, lock out / tag out

  • Heavy equiptment lifting (cranes, boom trucks, excavators)

  • Drilling borehole / excavations (Sub-surface clearance, locates)

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

  • Hot work (in potentially explosive atmosphere)

ensure all hazards identified are addressed in JSA below

  • 1. sequence of basic job Step in order

  • 1.potential hazards. (Ex. underground services, hazard zone etc.)

  • 1.safety controls to reduce or eliminate hazard

  • 2. sequence of basic job Step in order

  • 2. potential hazards. (Ex. underground services, hazard zone etc.)

  • 2. safety controls to reduce or eliminate hazard

  • 3. sequence of basic job Step in order

  • 3. potential hazards. (Ex. underground services, hazard zone etc.)

  • 3.safety controls to reduce or eliminate hazard

  • 4. sequence of basic job Step in order

  • 4. potential hazards. (Ex. underground services, hazard zone etc.)

  • 4.safety controls to reduce or eliminate hazard

  • 5. sequence of basic job Step in order

  • 5. potential hazards. (Ex. underground services, hazard zone etc.)

  • 5.safety controls to reduce or eliminate hazard

tools / Equipment ( list of tools and equipment and their storage on site, if relevant to safety

  • List

additional PPE ( minimum requirement: safety boots, hard hat, visi-vest, glasses, gloves)

  • Eye protection

  • Hearing protection

  • Fall protection

  • Rubber footwear and gloves if in a damp area

  • Portable gas monitor

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

outside authorities:

  • outside authorities

disposal of designated substances, surplus, or impacted materials (disposal details, e.g when, where, how?)

  • Add signature

retailer/Sales associate

  • prepared by

  • date

  • person carrying out work

  • date

  • person carrying out work

  • date

  • person carrying out work

  • date

site supervisor

  • JSA approved retailer/Sales associate signature

  • date

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