JSA CHECKLIST

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?

Visited the work site?

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

Is a written released procedure available? Has procedure gone through the LST review process? (If no, additional SME involvement and sign-off required). Procedure attached to JSA form? Procedure #

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?

Involved a Technical Expert or other SME (Subject Matter Experts) as applicable?

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)

HPU/ High Pressure Hoses

Whip Checks

Red Flashing Lights

Blast Shields with sand bags

Cameras/ Mirrors

Crane & Tag Lines

Spotter/Signaler

Rigging

Barrier Tape

Heating and Cooling

Manlift

Forklift

Fall Arrest System

Paltform ladder/Ladder

Lighting

Work Tables

Torque Tables

Hi-Torque

Pressure Washier

Spill Response Cart

Emergency Retrieval/Rescue Plan

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