Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel On Site
Work to Be Performed
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Description of Work to Be Performed:
How Could I Be Injured?
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Potential Hazards (Check all that apply):
- Body Position
- Lifting Hazard
- Hazardous Chemical Exposure
- Elevated Load or Work
- Pinch, Crush, or Striking Hazard
- Elevated Body Temperature
- Fall From Height
- Equipment Hazards
- Sharp Edges
- H2S Exposure
- RF/EME Exposure
- Fire or Explosion Potential
- Material Handling
- Hot/Cold Surfaces
- Slick/Slippery Surfaces
- Electrical Shock
- Ladders
- New Employees
- Subcontractors
- Excavation Hazard
- Confined Space
- Weather
- Slips, Trips, Falls
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List Other Potential Hazards:
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Photo of Potential Hazard
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Photo of Potential Hazard
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Photo of Potential Hazard
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What I'm Going to Do About the Hazards (Describe how you plan to work safely):
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Controls and Safe Work Practices to Ensure We Work Safely (Check all that apply):
- Confined Space Entry Procedure
- Contact One Call
- Restrict Access
- Use of PPE
- Sampling/Monitoring
- Tower Rescue Plan
- Lockout/Tagout
- Site/Job Orientation
- Drinking Water/Fluids
- Frequent Breaks
- Fire Extinguisher
- Fall Protection
- Gloves
- H2S Monitor
- RF Monitor
- Review Emergency Action Plan
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List Other Controls and Safe Work Practices
Acknowledgement (I have reviewed the JSA and agree to work safely)
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Signature
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Signature
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Signature
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Signature
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Signature
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Signature
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Signature
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Signature
