JSA Checklist revised 1/31

• Audit Title

• Client / Site

• Prepared by

• Date

  Date
• Location/Job
  Address

• Supervisor Name:

• Briefly describe the tasks and job steps to completing the activity.

JSA Checklist

• PPE

• Hard hats?

  Yes

  No

  N/A

• Safety glasses?

  Yes

  No

  N/A

• Safety Vest?

  Yes

  No

  N/A

• Steel Toe Boots

  Yes

  No

  N/A

• Other/ Miscellaneous PPE

  Yes

  No

  N/A

• Excavation

• Call before you dig

  Yes

  No

  N/A

• Sloping/Shoring:

  Safe

  At Risk

  N/A

• Sketch

  Drawing

• Access/Egress/Ladders

  Safe

  At Risk

  N/A

• Sketch

  Drawing

• Housekeeping

• Tripping/Stumbling Hazards?

  Safe

  At Risk

  N/A

• Excess materials?

  Yes

  No

  N/A

• Lunch trash?

  Yes

  No

  N/A

• Debris Handling?

  Yes

  No

  N/A

• Materials

• Hazardous Materials?

  Yes

  No

  N/A

• Material handling/transport

  Yes

  No

  N/A

• Hoisting

• Weight of pick/rigging

  0 to 5 tons

  5 to 10 tons

  10 to 15 tons

  15 to 20 tons

  20 to 25 tons

• Swing radius

  Safe

  At Risk

  N/A

• Proper signaling/radios?

  Yes

  No

  N/A

• Traffic

• Control devices?

  Yes

  No

  N/A

• Flaggers?

  Yes

  No

  N/A

• Fall Protection

• 100% Tie-off?

  Yes

  No

  N/A

• Secure tie-off points?

  Yes

  No

  N/A

• Hand railing

  Safe

  At Risk

  N/A

• Work platforms

  Safe

  At Risk

  N/A

• Access

• To work area

  Safe

  At Risk

  N/A

• To actual work

  Safe

  At Risk

  N/A

• Tools

• Tools required?

  Yes

  No

  N/A

• Tool hazards

  Safe

  At Risk

  N/A

• Sanitation

• Restroom?

  Yes

  No

  N/A

• Hand washing?

  Yes

  No

  N/A

• Drinking water?

  Yes

  No

  N/A

• Electrical

• Overhead Power Lines?

  Yes

  No

  N/A

• Items Requiring Lock-out/Tag-out

  Yes

  No

  N/A

• Safe Job Procedures/Suggestions

• Signatures of Those Attending

Employee

• Name

  Sign

• Signature of Supervisor

  Sign