Title Page
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Conducted on
JSA Checklist
Header
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Work \ Job \ Task Specific Location:
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Prepared By:
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Approved by:
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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
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HOT WORK
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CONFINED SPACE
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ENERGY ISOLATION - LOTO
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OTHER: (ie, cold work, open water, non flame, etc.)
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List permit required
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NONE:
HAVE YOU?
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Completed Pre-Job Planning/Potential Hazard Checklist and ensured appropriate hazard control methods implemented?
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Is a written released procedure available?
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Has everyone involved in the work particiapated in the JSA process?
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Has all personnel been assigned specific responsibilities and those responsibilities communicated/understood by all team members?
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JOB DESCRIPTION (general)
Personal Protective Equipment (check all that is appropriate)
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Safety Glasses
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Goggles
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Face Shield
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Hard Hat
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Gloves
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Type of gloves
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Safety Footwear
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Safety Harness / Fall Arrest
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Hearing Protection
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Protective Coveralls
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Respiratory Protection
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PPE OTHER
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List other:
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PFD - required working within 10 Ft. Of water
Special Equipment and/or Other Safety Precautions (Check all that apply)
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Spotter/Signaler
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Rigging
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Barrier Tape
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Heating and Cooling
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Manlift
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Forklift
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Fall Arrest System
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Paltform ladder/Ladder
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Lighting
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Torque Tables
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Pressure Washier
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Spill Response Cart
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Emergency Response Plan
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Fire Extinguisher
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Fire Watch
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Other:
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List other:
JSA Worksheet
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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
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Job Sequence - Task Breakdown (be specific & detailed)
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Identified Hazard(s)/Risks
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Hazard/Accident Controls
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Responsible Person(s) (be specific)
Task 2
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Job Sequence - Task Breakdown (be specific & detailed)
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Identified Hazard(s)/Risks
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Hazard/Accident Controls
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Responsible Person(s) (be specific)
Task 3
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Job Sequence - Task Breakdown (be specific & detailed)
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Identified Hazard(s)/Risks
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Hazard/Accident Controls
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Responsible Person(s) (be specific)
Task 4
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Job Sequence - Task Breakdown (be specific & detailed)
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Identified Hazard(s)/Risks
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Hazard/Accident Controls
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Responsible Person(s) (be specific)
Task 5
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Job Sequence - Task Breakdown (be specific & detailed)
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Identified Hazard(s)/Risks
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Hazard/Accident Controls
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Responsible Person(s) (be specific)
JSA Sign Off
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Technician Name:
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Technician Name:
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