JSA Walk up

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Walk up observation

• Everyone wearing ppe

  Safe

  At Risk

  N/A

• Does work crew have JSA with them

  Yes

  No

  N/A

General

• Work order number filled in

  Yes

  No

  N/A

• Date filled in

  Yes

  No

  N/A

• Time filled in

  Yes

  No

  N/A

• Location filled in

  Yes

  No

  N/A

• Work description specific for task

  Yes

  No

  N/A

• Participant name and signature filled in

  Yes

  No

  N/A

• Supervisor sign and dated

  Yes

  No

  N/A

Job sight assessment

• Filled out at job site

  Yes

  No

  N/A

• What should of been marked on sight assessment

Safe work assessment

• Job hazard identified that can not be corrected at this time<br>

  Yes

  No

  N/A

• If yes was a safety work order initiated

  Yes

  No

  N/A

• Does everyone involved with work under stand job scope

  Yes

  No

  N/A

• Has the job been made safe for all

  Yes

  No

  N/A

2 minute rule

• Are all blocks marked on two minute rule

  Yes

  No

  N/A

• What was not marked

  Select hazards identified are we on correct equipment components ID tags are correct right tools for the job how could we get hurt housekeeping and lighting adequate all possible hazards identified risk from hazards identified technical aspect identified proper ppe any environmental concerns do conditions match has do we need to change plans correct paperwork what could go wrong how do we avoid line of fire

  • hazards identified
  • are we on correct equipment
  • components ID tags are correct
  • right tools for the job
  • how could we get hurt
  • housekeeping and lighting adequate
  • all possible hazards identified
  • risk from hazards identified
  • technical aspect identified
  • proper ppe
  • any environmental concerns
  • do conditions match has
  • do we need to change plans
  • correct paperwork
  • what could go wrong
  • how do we avoid line of fire

Job hazard checklist

• Was job hazards checklist filled out

  Yes

  No

  N/A

• Was all hazards that pertained to the job identified<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Human hazards

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

human performance

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Plant and animal

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Chemical biological measures

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

General safety preventive measures

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Personal protective equipment

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Emergency info / equipment location

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Permits

• Confined space permit

  Yes

  No

  N/A

• Clearance required

  Yes

  No

  N/A

• Hot work number filled in

  Yes

  No

  N/A

• Clearance accepted and sign on

  Yes

  No

  N/A

• Grating removal open hole

  Yes

  No

  N/A

• Clearance permit tags signed

  Yes

  No

  N/A

• Excavation permit required

  Yes

  No

  N/A

• Other required

  Yes

  No

  N/A

Fall protection

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Excavation

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Welding

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Electrical

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Scaffolding/ladder

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Crane lifting equipment

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Tools

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

Environmental

• Were hazards identified in this section

  Yes

  No

  N/A

• Was all hazards that pertained to the job marked<br><br>

  Yes

  No

  N/A

• What was not identified that should of been

• Auditor

  Sign

• Who was audited

  Sign