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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.