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, STOP WORK.
  
  
  4 When existing JSA is used, it must review and revised to identify current hazards
  
  
  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?

• 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?

• 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

• 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

• Job Sequence - Task Breakdown (be specific & detailed)

• Identified Hazard(s)/Risks

• Hazard/Accident Controls

• Responsible Person(s) (be specific)

JSA Sign off

• Sign

  Sign

• Select date

  Date
Site approved

• sign

  Sign