JOB SAFETY ANALYSIS

• Date/Time Issued

  Date

• Prepared by

• Client Name

• Site Name

• Address

• Nearest Medical Facility

• Address

• Phone

• 1.

• 2.

• 3.

• 4.

• 5.

• 6.

PHYSICAL HAZARDS

• Driving/Traffic

  Safe

  At Risk

  N/A

• Equipment

  Safe

  At Risk

  N/A

• Walking/Working Surfaces

  Safe

  At Risk

  N/A

• Hand/Power Tools

  Safe

  At Risk

  N/A

• Sharp Edges/Cuts

  Safe

  At Risk

  N/A

• Noise

  Safe

  At Risk

  N/A

• Overhead Hazards

  Safe

  At Risk

  N/A

• Falling Objects

  Safe

  At Risk

  N/A

• Working at Heights

  Safe

  At Risk

  N/A

• Vibration

  Safe

  At Risk

  N/A

• Underground Utilities

  Safe

  At Risk

  N/A

• Weather

  Safe

  At Risk

  N/A

• Confined Space Entry

  Safe

  At Risk

  N/A

• Flammable Atmosphere

  Safe

  At Risk

  N/A

• Combustible Dust

  Safe

  At Risk

  N/A

• Oxygen Enriched

  Safe

  At Risk

  N/A

• Oxygen Deficient

  Safe

  At Risk

  N/A

• Toxic Atmosphere

  Safe

  At Risk

  N/A

• Engulfment

  Safe

  At Risk

  N/A

• Entrapment

  Safe

  At Risk

  N/A

• Entanglement

  Safe

  At Risk

  N/A

• Sloped Floor/Cone Bottom

  Safe

  At Risk

  N/A

ERGONOMIC/BIOLOGICAL

• Overexertion/Fatigue

  Safe

  At Risk

  N/A

CHEMICAL

• Asbestos

  Safe

  At Risk

  N/A

• Lead-Based Paint

  Safe

  At Risk

  N/A

• Other

  Safe

  At Risk

  N/A

• Hazard Class

  Select

ENERGY

• Energy Hazards

  Safe

  At Risk

  N/A

• Electrical

  Safe

  At Risk

  N/A

• Mechanical

  Safe

  At Risk

  N/A

• Pneumatic

  Safe

  At Risk

  N/A

• Hydraulic

  Safe

  At Risk

  N/A

• Pressure

  Safe

  At Risk

  N/A

• Vacuum

  Safe

  At Risk

  N/A

• Fluids

  Safe

  At Risk

  N/A

• Compressed Gas

  Safe

  At Risk

  N/A

Engineering/Administrative

• Pre-Trip Inspection

• Safe Driving Practices

• Follow Established SOPs

• Housekeeping

• Verify Utility Locates

• Distance to Overhead Wires

• Caution/Danger Tape

• Moisture

• Ventilation

• Glove Bag/Enclosure

• Barrier Cream/Sunscreen

• Insect Repellent

• Other

Personal Protective Equipment

• Hardhat

• Eye/Face Protection

• Hearing Protection

• Body

• undefined

  Select Level D Level D, FR Level C

  • Level D
  • Level D, FR
  • Level C

• Gloves

• Boots

• Footwear Traction Devices

• Respiratory Protection

• Fall Protection

• High Visibility Clothing

Tools & Equipment

• undefined

Communication

• undefined

• We reviewed the work authorized by this permit and the information it contains. We received safe work procedures and understand the hazards present in this area. This assessment is not complete unless all appropriate sections are reviewed. We understand to immediately report any close calls, injuries, equipment/property damage, or environmental releases to the project manager.

• Signature

  Sign

• Were you injured today?

  No

  Yes

• Signature

  Sign

• Were you injured today?

  No

  Yes

• Signature

  Sign

• Were you injured today?

  No

  Yes

• Signature

  Sign

• Were you injured today?

  No

  Yes

• Signature

  Sign

• Were you injured today?

  No

  Yes