Title Page

  • Conducted on

JSA Checklist

Header

  • Work \ Job \ Task Specific Location:

  • Prepared By:

  • Approved by:

  • JSA REQUIREMENTS
    1 The JSA must be reviewed/revised daily, after a stoppage in work, or if work conditions change (i.e., weather, change in plan, etc.)


    2 Changes, new identified hazards and/or JSA revisions must be communicated to all team members.


    3 If identified hazards cannot be controlled by the JSA, further risk assessment and management approval is required.


    4 When existing JSA is used, it must review and revised to identify current hazards and approved by supervision


    5 Completed JSAs and attachments must be maintained for at least one year.


    6 A debriefing should be performed after the job has been completed and any lessons learned captured and communicated for use in future JSAs.

Permit(s) Required

  • HOT WORK

  • CONFINED SPACE

  • ENERGY ISOLATION - LOTO

  • OTHER: (ie, cold work, open water, non flame, etc.)

  • List permit required

  • NONE:

HAVE YOU?

  • Completed Pre-Job Planning/Potential Hazard Checklist and ensured appropriate hazard control methods implemented?

  • Is a written released procedure available?

  • Has everyone involved in the work particiapated in the JSA process?

  • Has all personnel been assigned specific responsibilities and those responsibilities communicated/understood by all team members?

  • JOB DESCRIPTION (general)

Personal Protective Equipment (check all that is appropriate)

  • Safety Glasses

  • Goggles

  • Face Shield

  • Hard Hat

  • Gloves

  • Type of gloves

  • Safety Footwear

  • Safety Harness / Fall Arrest

  • Hearing Protection

  • Protective Coveralls

  • Respiratory Protection

  • PPE OTHER

  • List other:

  • PFD - required working within 10 Ft. Of water

Special Equipment and/or Other Safety Precautions (Check all that apply)

  • Spotter/Signaler

  • Rigging

  • Barrier Tape

  • Heating and Cooling

  • Manlift

  • Forklift

  • Fall Arrest System

  • Paltform ladder/Ladder

  • Lighting

  • Torque Tables

  • Pressure Washier

  • Spill Response Cart

  • Emergency Response Plan

  • Fire Extinguisher

  • Fire Watch

  • Other:

  • List other:

JSA Worksheet

  • For each identified hazard, you should always attempt to address/control using the below methods in the following order:

    1. Eliminate or remove the hazard when and whereever possible.


    2. Substitute- if the hazard cannot be eliminated or removed, can we use a less hazardous substitute?


    3. Engineering Controls- if the hazard cannot be eliminated or a less hazardous substitution used, can we incorporate an engineering control device i.e., physical guarding/barrier that prevents access/exposure to the hazard? Wherever possible, "engineer out


    4. Administrative Controls- This is an important element but DOES NOT guarantee anyone's safety.

    Examples include: Training, policy & procedures, safety/JSA briefings, verbal instructions/directives, etc


    5. PPE- Ensure that the appropriate level of PPE is provided and used based upon the associated risk/hazards.

Task 1

  • Job Sequence - Task Breakdown (be specific & detailed)

  • Identified Hazard(s)/Risks

  • Hazard/Accident Controls

  • Responsible Person(s) (be specific)

Task 2

  • Job Sequence - Task Breakdown (be specific & detailed)

  • Identified Hazard(s)/Risks

  • Hazard/Accident Controls

  • Responsible Person(s) (be specific)

Task 3

  • Job Sequence - Task Breakdown (be specific & detailed)

  • Identified Hazard(s)/Risks

  • Hazard/Accident Controls

  • Responsible Person(s) (be specific)

Task 4

  • Job Sequence - Task Breakdown (be specific & detailed)

  • Identified Hazard(s)/Risks

  • Hazard/Accident Controls

  • Responsible Person(s) (be specific)

Task 5

  • Job Sequence - Task Breakdown (be specific & detailed)

  • Identified Hazard(s)/Risks

  • Hazard/Accident Controls

  • Responsible Person(s) (be specific)

JSA Sign Off

  • Technician Name:

  • Technician Name:

  • Technician Name:

  • Technician Name:

  • Technician Name:

  • Technician Name:

  • Technician Name:

  • Technician Name:

  • Technician Name:

  • Technician Name:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.