JSA Audit Form

• Document No.

• Project Name

• Auditor

• Location
  Address

• Conducted on

  Date

• Contractors

Administration / Program

• Does the Safety Station have all of the following information; current safety information, JSA,,construction safety sign, SDS, Daily inspection checklist?

  Yes

  No

  N/A

• Is work described on the JSA consistent with the work described on permit?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Is the work described the same as the work being preformed?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Is the general Information section of the JSA filled out completely and correctly?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Do Crew members Understand What actions to take in the event of an Emergency?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Has the supervisor / lead person identified a Job scope and communicated it correctly if needed?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Has the JSA been reviewed By a supervisor or lead person?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Did the Crew members have input on the JSA?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Have the Permits been reviewed with the crew for complete understanding?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Are these permits available on work location

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Does the JSA indicate possible hand injuries? and has the potential Hazards of line of fine been discussed?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• is elevated work being preform and specified on the JSA ?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Have prevention/ mitigation been addressed to the appropriate corresponding Hazards?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Does the JSA specify the appropriate PPE?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Is the PPE being use, in good working condition?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• If chemicals are being used, does the JSA address this and been communicated with crew?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Has LOTO been clearly identified and walked down, and properly documented on JSA and permit?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Has everyone preforming work reviewed / signed the JSA form?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

• Is there a time next to Supers Signature?

  NO-Not properly identified or addressed on JSAor at work

  Identified on JSA but did not address at work location

  Hazards addressed At work location but not identified on JSA

  Properly Identified and addressed on JSA but needs improvement

  yes - Properly identified and addressed on JSA and at work location

stakeholders

• PM or CM

  Sign

• Auditor.

  Sign