JSA Remote

• Jobsite
  Address

• Branch

• Customer

• Date

  Date

• Point of Contact

• What type of work is the job order for?

A. General

• 1. Emergency phone numbers and procedures posted?

  Yes

  No

  N/A

• 2. First aid supplies readily available?

  Yes

  No

  N/A

• 3. Required posters and signs posted and readable?

  Yes

  No

  N/A

• 4. Site assigned clinic or hospital is posted and up to date?

  Yes

  No

  N/A

B. Personal Protective Equipment

• 1. PPE worn by all personnel in work areas?

  Yes

  No

  N/A

• 2. Respiratory protection worn as required?

  Yes

  No

  N/A

• 3. Safety harnesses and lanyards worn for fall protection?

  Yes

  No

  N/A

• 4. Workers dressed properly for the job?

  Yes

  No

  N/A

• 5. Personal protective equipment in good condition?

  Yes

  No

  N/A

• 6. Safety supplies adequate for job manpower?

  Yes

  No

  N/A

C. Housekeeping

• 1. Walkways and stairs kept clear of material and debris?

  Yes

  No

  N/A

• 2. Are cords and hoses organized or hung to prevent trip and fall hazard?

  Yes

  No

  N/A

• 3. Trash, scrap, and debris picked up and disposed of?

  Yes

  No

  N/A

D. Fire Protection

• 1. Is fire hazard safety equiptment inspected and in good condition?

  Yes

  No

  N/A

• 2. Is fire hazard safety equiptment in accessable and in well marked locations?

  Yes

  No

  N/A

• 3. Are flamable liquids kept in a ventlated and secure location?

  Yes

  No

  N/A

• 4. Are Oxidizers kept separate a secured?

  Yes

  No

  N/A

E. Material Handling and Storage

• 1. Materials are stored and organized in approprate locations?

  Yes

  No

  N/A

• 2. Stored materials with sharp edges are barricaded from accidental abrasion?

  Yes

  No

  N/A

• 3. Are materials being lifted and handed safely and with appropriate PPE?

  Yes

  No

  N/A

• 4. Are hazardous materials approprately labled and in undamaged containers?

  Yes

  No

  N/A

F. Power Tools

• 1. Are gaurds being used on tools that require them?

  Yes

  No

  N/A

• 2. Are tools grounded (ground prong) or double insulated?

  Yes

  No

  N/A

• 3. Are tools kept in good condition and inspected before use?

  Yes

  No

  N/A

G. Welding and Cutting

• 1. Are caps secured on all cylinders not in use?

  Yes

  No

  N/A

• 2. All Cilinders and hoses are inspected for leaks and damage?

  Yes

  No

  N/A

• 3. Welding leads organized and in good condition?

  Yes

  No

  N/A

• 4. Fire extinguishers kept close to hot work areas?

  Yes

  No

  N/A

• 5. Are flamable materials protected or removed from hot zones?

  Yes

  No

  N/A

• 6. Are grinders being used with faceshields?

  Yes

  No

  N/A

H. Electrical

• 1. Are extension cords used an unmodified heavy duty 3-wire type?

  Yes

  No

  N/A

• 2. Are extension cords being used un-damaged and kept in good condition?

  Yes

  No

  N/A

• 3. Are Lock Out Tag Out procedured utilized in energized systems?

  Yes

  No

  N/A

• 4. Temporary power point are inspected and in good condition?

  Yes

  No

  N/A

• 5. Extension cords are being used with a GFCI and are not daisy-chained?

  Yes

  No

  N/A

I. Ladders

• Straight ladders secured at top landing?

  Yes

  No

  N/A

• Straight ladders set up with a 4 to 1 slope?

  Yes

  No

  N/A

• Top step of stepladders not used as a step?

  Yes

  No

  N/A

• Are Ladders inspected for damage and all signage legible?

  Yes

  No

  N/A

J. Scaffolds

• All scaffold parts and hardware are used as required?

  Yes

  No

  N/A

• All scaffold hardware and parts are in good condition?

  Yes

  No

  N/A

• All scaffold are inspected with respective tags?

  Yes

  No

  N/A

K. Industrial Vehicles and Man Lifts

• Are vehicles and man lifts inspected daily and in good condition?

  Yes

  No

  N/A

• Is the safety equiptment in all vehicles and man lifts fully functional?

  Yes

  No

  N/A

• Are operators manuels and fire extinguishers present and in good condition?

  Yes

  No

  N/A

• Are all operators certified on the equiptment they are using?

  Yes

  No

  N/A

L. Handrails and Hole Covers

• Railings are sturdy and continuous with midrails and toe boards?

  Yes

  No

  N/A

• Floor holes protected by railings or secured hole covers?

  Yes

  No

  N/A

• Exposed edges have adequate barriers or engineered controls?

  Yes

  No

  N/A

M. Excavation and Trenching

• Excavations 5' or deeper shored, sloped, or boxed?

  Yes

  No

  N/A

• Workers stay within shored area?

  Yes

  No

  N/A

• Adequate access and egress points are provided ?

  Yes

  No

  N/A

• Are barricades provided for excavations deeper than 5'?

  Yes

  No

  N/A

N. Employee Communications

• Do foremen communicate with their crews on job methods?

  Yes

  No

  N/A

• Do foremen react to employee safety recommendations?

  Yes

  No

  N/A

• Do foremen address unsafe actions and conditions?

  Yes

  No

  N/A

• Are safety meetings held weekly with all employees?

  Yes

  No

  N/A

General Site Hazards:

• General Site Hazards

Traffic Conditions on Site:

• Traffic Conditions on Site

Other

• Is there night work?

  Yes

  No

  N/A

• Is there proper lighting?

  Yes

  No

  N/A

• Are there any hazards getting on and off site?

  Yes

  No

  N/A

• Is there on site parking?

  Yes

  No

  N/A

Name and Signitures

• Client Name:

• Signiture:

  Sign

• Staff Name:

• Signiture:

  Sign