JSA

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Details

• Location:

• Activity or task:

• Photo of job task:

  Media

Work Step 1

• Describe the first step involved in the work

• Can someone be struck or contacted by anything?

  Safe

  At Risk

  N/A

• Can someone strike against or make contact with any physical hazards.

  Safe

  At Risk

  N/A

• Can someone be exposed to any hazardous conditions?

  Safe

  At Risk

  N/A

• Can someone slip, trip or fall?

  Safe

  At Risk

  N/A

• Can someone fall into anything?

  Safe

  At Risk

  N/A

• Can someone strain or over exert?

  Safe

  At Risk

  N/A

• Can damage to equipment occur?

  Safe

  At Risk

  N/A

• Can someone be caught in anything?

  Safe

  At Risk

  N/A

• Can someone injure someone else?

  Safe

  At Risk

  N/A

• Risk level

  Extreme

  High

  Moderate

  Low

• Safety controls for this step

Work Step 2

• Describe the next step involved in the work

• Can someone be struck or contacted by anything?

  Safe

  At Risk

  N/A

• Can someone strike against or make contact with any physical hazards.

  Safe

  At Risk

  N/A

• Can someone be exposed to any hazardous conditions?

  Safe

  At Risk

  N/A

• Can someone slip, trip or fall?

  Safe

  At Risk

  N/A

• Can someone fall into anything?

  Safe

  At Risk

  N/A

• Can someone strain or over exert?

  Safe

  At Risk

  N/A

• Can damage to equipment occur?

  Safe

  At Risk

  N/A

• Can someone be caught in anything?

  Safe

  At Risk

  N/A

• Can someone injure someone else?

  Safe

  At Risk

  N/A

• Risk level

  Extreme

  High

  Moderate

  Low

• Safety controls for this step

Work Step 3

• Describe the next step involved in the work

• Can someone be struck or contacted by anything?

  Safe

  At Risk

  N/A

• Can someone strike against or make contact with any physical hazards.

  Safe

  At Risk

  N/A

• Can someone be exposed to any hazardous conditions?

  Safe

  At Risk

  N/A

• Can someone slip, trip or fall?

  Safe

  At Risk

  N/A

• Can someone fall into anything?

  Safe

  At Risk

  N/A

• Can someone strain or over exert?

  Safe

  At Risk

  N/A

• Can damage to equipment occur?

  Safe

  At Risk

  N/A

• Can someone be caught in anything?

  Safe

  At Risk

  N/A

• Can someone injure someone else?

  Safe

  At Risk

  N/A

• Risk level

  Extreme

  High

  Moderate

  Low

• Safety controls for this step

Work Step 4

• Describe the next step involved in the work

• Can someone be struck or contacted by anything?

  Safe

  At Risk

  N/A

• Can someone strike against or make contact with any physical hazards.

  Safe

  At Risk

  N/A

• Can someone be exposed to any hazardous conditions?

  Safe

  At Risk

  N/A

• Can someone slip, trip or fall?

  Safe

  At Risk

  N/A

• Can someone fall into anything?

  Safe

  At Risk

  N/A

• Can someone strain or over exert?

  Safe

  At Risk

  N/A

• Can damage to equipment occur?

  Safe

  At Risk

  N/A

• Can someone be caught in anything?

  Safe

  At Risk

  N/A

• Can someone injure someone else?

  Safe

  At Risk

  N/A

• Risk level

  Extreme

  High

  Moderate

  Low

• Safety controls for this step

Work Step 5

• Describe the next step involved in the work

• Can someone be struck or contacted by anything?

  Safe

  At Risk

  N/A

• Can someone strike against or make contact with any physical hazards.

  Safe

  At Risk

  N/A

• Can someone be exposed to any hazardous conditions?

  Safe

  At Risk

  N/A

• Can someone slip, trip or fall?

  Safe

  At Risk

  N/A

• Can someone fall into anything?

  Safe

  At Risk

  N/A

• Can someone strain or over exert?

  Safe

  At Risk

  N/A

• Can damage to equipment occur?

  Safe

  At Risk

  N/A

• Can someone be caught in anything?

  Safe

  At Risk

  N/A

• Can someone injure someone else?

  Safe

  At Risk

  N/A

• Risk level

  Extreme

  High

  Moderate

  Low

• Safety controls for this step

RISK GUIDE

Likelihood

• A - ALMOST CERTAIN - Is expected to occur in most circumstances

• B - LIKELY - Will probably occur in most circumstances

• C - POSSIBLE - Might occur at some time

• D - UNLIKELY - Could occur at some time

• E - RARE - May occur only in exceptional circumstances

CONSEQUENCES

• 1 - INSIGNIFICANT - No injuries

• 2 - MINOR - First aid treatment, any spills contained on site

• 3 - MODERATE - Medical treatment required, spills contained on site but with outside help

• 4 - MAJOR - Extensive injuries, loss of production

• 5 - CATASTROPHIC - Death, toxic chemicals released

RISK LEVEL

• CONSEQUENCES

• LIKELIHOOD INSIGNIFICANT MINOR MODERATE MAJOR CATASTROPHIC

• A (almost certain) H H E E E

• B (likely) M H H E E

• C (possible) L M H E E

• D (unlikely) L L M H E

• E (rare) L L M H H

E = EXTREME RISK H = HIGH RISK M = MODERATE RISK L = LOW RISK

STAFF & CONTRACTORS (Personnel below have been made aware and understand the procedure, hazards and control measures above)

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APPROVED BY

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  Date

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