JSA Audit Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• JSA number

• JSA Review is to be carried out by asking the following questions (answer yes or no if the JSA meets required standards) Add any further action required

JSA Review

• Is the JSA located on the job and its location known?

  Yes

  No

  N/A

• Is the JSA signed by the employee/s before the task is started?<br>

  Yes

  No

  N/A

• Was the employee/s involved in the development of the JSA?

  Yes

  No

  N/A

• Has the JSA been reviewed (today) by the employee/s doing the task? If "NO" see points 15-16.

  Yes

  No

  N/A

• Are the JSA steps consistent with the activity being carried out? (ask person to explain the task)

  Yes

  No

  N/A

• Are the hazards identified in the JSA consistent with the task area?

  Yes

  No

  N/A

• Have hazard controls been identified and implemented?

  Yes

  No

  N/A

• Are hazard controls adequate for the task?

  Yes

  No

  N/A

• Are individuals responsibilities clearly defined?

  Yes

  No

  N/A

• Have persons received adequate JSA training? If yes, describe what/when

  Yes

  No

  N/A

• Does the JSA identify task specific requirements including: Personnel, Equipment/Tools, Process Controls, Permits, etc?

  Yes

  No

  N/A

• Has a specific means of communication been identified?

  Yes

  No

  N/A

• Are emergency procedures clearly defined for the task?

  Yes

  No

  N/A

• Is 'Safe Talk' Practise in the team and what was the feedback received, by whom?

  Yes

  No

  N/A

Action

• General Comments

• Further action required

  Yes

  No

  N/A

• By Whom?

• By When?

• Add signature

  Sign

• Add signature

  Sign