Title Page
-
Site conducted
-
Document No.
-
Conducted on
Permit Questions
-
JSA
SAFE HOME EVERY DAY -
Job Type
-
Site Controller
-
Location
- A Block
- B Block
- Winding
- Twisting
- Blending
- Dyehouse
- Confin
- Despatch
- Services
- External
- Upstairs
-
Photo of job location
-
Select date
-
Names of personnel performing the task
- Justin Wood
- Rob Brady
- Dean Aitken
- Adrian Kiwara
- Glen Simpson
- Simon Jowett
- Ben Earnshaw
- Other - please list below
- Leo Singh
-
names of other personnel involved
-
All persons named above must sign
-
-
Identify potential hazards - Consult all stakeholders
-
Photos of Hazards Identified
-
Description of method of control(Eliminate, Isolate and/or Minimize) How will you control the hazards to reduce the risk to an acceptable level
-
Photos of Controls in place
-
NO WORK TO COMMENCE UNTIL THE SECTION BELOW IS COMPLETED AND ANY REQUIRED PERMITS ARE ISSUED
-
DOES THE WORK INCLUDE
-
Naked flame, Welding, Grinding, Concrete Cutting/Drilling without water.
-
IF YES, OBTAIN REQUIRED HOT WORK PERMIT - INPUT PERMIT NUMBER BELOW.
-
Entry to Tanks, Trenches, Pits, Tunnels, Dryer Cabinets, etc
-
IF YES, OBTAIN REQUIRED CONFINED SPACE ENTRY PERMIT - INPUT PERMIT NUMBER BELOW.
-
Digging Trenches, Earth moving, Demolition, Installation
-
IF YES, OBTAIN REQUIRED EXCAVATION, DEMOLITION & INSTALLATION PERMIT - INPUT PERMIT NUMBER BELOW.
-
Roof Access or Working at Heights
-
IF YES, OBTAIN REQUIRED WORKING AT HEIGHTS PERMIT - INPUT PERMIT NUMBER BELOW.
-
JSA APPROVED BY
-
ISSUE DATE
-
REVIEW DATE
