Title Page
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Conducted on
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Prepared by
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Location
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Is a JSA on location and being utilized?
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Is the JSA current for daily tasks?
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Is emergency information in place?
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Is emergency information up to date?
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Is location identified on the JSA?
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Is specific Job Task identified on the JSA?
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Is the date, time, and weather specified on the JSA?
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Are activities being performed covered on the JSA?
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Does the JSA identify hazards associated with the job steps/ activities?
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Are preventative measures /controls identified?
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Are preventative measures/controls understood?
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Are preventative measures being followed?
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Is the required PPE identified in the JSA?
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Is the proper PPE being used correctly?
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Are all required personnel signed on the JSA?
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Personnel listed on the JSA understands the task and their responsibilities?
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Specific safety equipment and required permits are in place?
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Is there a work Instruction for task being performed?
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Does the JSA coincide with the work task instructions?
JSA Pictures
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Take a picture of the JSA
Signatures
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Supervisor On Site:
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HSE Representative: