JSA - Risk Assessment

• 1. This form must be completed each day at the first work site. New hazards identified that are NOT on the HAC relating to a specific task, must be recorded within the additional and significant hazards section.

• 2. Complete a new form whenever conditions change I.E type of work site, work activities , significant Hazards.

• Date:

  Date

• Client Name:

• Prepared by:

• Location:
  Address

• Photos of Job:

  Yes

  No

  N/A

• Emergency Contact Number:

  000

• Evacuation Point / Assembly Area

  Truck

• First Aid Kit Location/s

  Truck Cab - Behind seat

• EMERGENCY
  • In an emergency
  
  • Evacuate all persons on site to designated assembly area.
  
  • Lock down the site if possible
  
  • Contact Emergency Services

• PIC - Person in charge: I am responsible for conducting the crew risk assessment and ensuring that control measures are implemented by all crew Members

• C/M - Crew Member: I am responsible for ensuring the safety of myself and others and adhering the Rick assessment.

• V - Visitor: I am responsible for ensuring that I am briefed on the risk assessment and control plan, wear required PPE, adhere to control measures and follow all instructions.

Crew / Visitor Sign on - Required for every person entering the worksite.

• Add drawing

  Drawing
Worker

• Role:

• Name:

  Sign

• Date:

  Date

PIC required information

• PIC has confirmed verbally with all the crew onsite, that they have All the relevant licenses & white cards with them today.

  Yes

  No

  N/A

• If No, an incident report must be completed, and the person/s must leave the worksite immediately.

• List the main task that will be preformed on this site.

Task 1

• Job Activities

• List of swms in use for this job ( if applicable):

  Select Tools Operation (Powered/Non-Powered) Wood Chipper Operation Working At Height Tree Felling (Mechanical) Tree Trimming (EWP - Rope Work) Tree Felling (Manual) Manual Handling

  • Tools Operation (Powered/Non-Powered)
  • Wood Chipper Operation
  • Working At Height
  • Tree Felling (Mechanical)
  • Tree Trimming (EWP - Rope Work)
  • Tree Felling (Manual)
  • Manual Handling

• Have all relevant workers read the SWMS?

  Safe

  At Risk

  N/A

• Have all the works been trained in the SWMS?

  Yes

  No

  N/A

• Tick the boxes for the activities relevant to the work location/s. Ensure that specific risk control measures have Been put in place as per the safe work method statement (SWMS).

  Select Tree Climbing Chipper Herbicide Use Working out doors Skid steer use Tree felling Blower EWP Driving Working near powerlines Tree Pruning Power pruner Excavator Use Fueling Working near rail Chainsaw Use Stump Grinding Avant Use ATV Use Traffic Management

  • Tree Climbing
  • Chipper
  • Herbicide Use
  • Working out doors
  • Skid steer use
  • Tree felling
  • Blower
  • EWP
  • Driving
  • Working near powerlines
  • Tree Pruning
  • Power pruner
  • Excavator Use
  • Fueling
  • Working near rail
  • Chainsaw Use
  • Stump Grinding
  • Avant Use
  • ATV Use
  • Traffic Management

• Write in any new hazards identified (i.e not stranded HAC) And significant hazards for the worksite. Write down control measures to be applied. If you cannot control hazard stop work and contact your supervisor.

Additional & Significant Hazards / Control Measures

• HAZARD:

• CONTROL MEASURE:

• Traffic Control Diagram/s used (TCP No.) :

• HB 436:2004 Risk Management Guidelines Tables 6.3 – 6.8 reproduced with permission from SAI Global under licence 1210-c062. Standards may be purchased at http://www.saiglobal.com
  References: Safe Work Australia (2011) - Code of Practice: How to Manage Work Health and Safety Risks, AS/NZS 31000 -2009 Risk Management Principles and Guidelines.

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