JSA

• Conducted on

  Date

• Prepared by

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:

• 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)

• Technician Name:

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