JSA / Jobsite Safety Audit

• Document No.

• Superintendent:

• Conducted on

  Date

• Prepared by

• Location
  Address

JSA / Audit

• Date and time

  Date

• Job Description

• Work location

• IS SPECIAL TRAINING REQUIRED?

  YES

  NO

• Are All Employees Briefed On The Hazards Of This Job?

  Yes

  No

  N/A

• Will Weather Affect The Safe Execution Of This Work?

  YES

  NO

PROCEDURES OR PERMITS REQUIRED:

• Fill Out and Attach Appropriate Tag?

  Yes

  No

  N/A

• Fill Out Confined Space Permit?

  Yes

  No

  N/A

• Fill Out Daily Excavation Safety Checklist

  Yes

  No

  N/A

• Fill out Hot Work Permit

  Yes

  No

  N/A

• Fill Out Barricade Tag

  Yes

  No

  N/A

• OTHER (Enter Description)

COMPETENT PERSON CHECKLIST:

Trench and Excavation:

• Sloped or Shielded Excavation (Over 5vf)

  Yes

  No

  N/A

• Spoil Pile Greater Than 2lf From Edge of Excavation

  Yes

  No

  N/A

• No Water Present

  Yes

  No

  N/A

• Means of Egress and Access

  Yes

  No

  N/A

Confined Space:

• Air Monitor

  Yes

  No

  N/A

• Confined Space Attendant Sign IN/OUT

  Yes

  No

  N/A

• Ventilation System

  Yes

  No

  N/A

• Retraction (Rescue) Device

  Yes

  No

  N/A

Lifting or Rigging:

• Certified Chains

  Yes

  No

  N/A

• Slings, Hooks, Clevices

  Yes

  No

  N/A

• Identify Weight of Materials Being Lifted

  Yes

  No

  N/A

• Verify Reach and Load Limits of Equipment Doing Lifting (Verify Equipment Specific Lifting Chart)

  Yes

  No

  N/A

Fall Protection:

• Is Work Over 6vf Off The Ground? (If Yes, Fall Protection Required)

  YES

  NO

• ADDITIONAL COMMENTS:

EMPLOYEE SIGNATURES:

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