Title Page

  • Conducted on

  • Prepared by

  • Location
  • Is a JSA on location and being utilized?

  • Is the JSA current for daily tasks?

  • Is emergency information in place?

  • Is emergency information up to date?

  • Is location identified on the JSA?

  • Is specific Job Task identified on the JSA?

  • Is the date, time, and weather specified on the JSA?

  • Are activities being performed covered on the JSA?

  • Does the JSA identify hazards associated with the job steps/ activities?

  • Are preventative measures /controls identified?

  • Are preventative measures/controls understood?

  • Are preventative measures being followed?

  • Is the required PPE identified in the JSA?

  • Is the proper PPE being used correctly?

  • Are all required personnel signed on the JSA?

  • Personnel listed on the JSA understands the task and their responsibilities?

  • Specific safety equipment and required permits are in place?

  • Is there a work Instruction for task being performed?

  • Does the JSA coincide with the work task instructions?

JSA Pictures

  • Take a picture of the JSA

Signatures

  • Supervisor On Site:

  • HSE Representative:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.