iAuditor Mobile App Preview

Audit

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

JOB SAFETY ANALYSIS (JSA) FORM CHECKLIST

Created by: aurora mechanical ltd | Industry: Professional Services | Downloads: 8,184

POST TRAINING JSA FORM

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

Browse for other checklists


iauditor logo

The World's #1 Cloud-Based Inspection Software and App

chevron logo
coles logo
emirates logo
overground logo
tesla logo
toyota logo

Audit

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