NHP JSA

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

site information

• task activity

• date

  Date

• Service order number SON

• name of contractor/Subcontractor

Work Statement Checklist

• Equipment to be installed or removed

  N/A

  Discussed

• Compatibility of proposed equipment with existing equipment.

  N/A

  Discussed

• The working which might be affected.

  N/A

  Discussed

• When working equipment will be taken out of service.

  N/A

  Discussed

• Proximity of power plants and disturbing systems

  N/A

  Discussed

• The steps requiring the presence of an on site representative.

  N/A

  Discussed

• Identify alarms to be disconnected and when.

  N/A

  Discussed

• Records and drawings to be corrected.

  N/A

  Discussed

• Protection of equipment, floor, walls, etc.

  N/A

  Discussed

• Storage of tools and materials.

  N/A

  Discussed

• Service restoration procedure and responsibility and back up plans

  N/A

  Discussed

• Detailed step by step procedure.

  Yes

  No

  N/A

• Stipulate normal shift time

  N/A

  Discussed

• Documentation approved

  N/A

  Discussed

• Equipment protection procedures

  N/A

  Discussed

• Dust containment procedures.

  N/A

  Discussed

• Emergency contact details

  N/A

  Discussed

critical procedures: where work involves any of the following hazards must be incorporated into JSA

• Work at heights above 1.5m

  Yes

  No

  N/A

• Confined space entry (includes tank cleaning)

  Yes

  No

  N/A

• Electrical/Mechanical lockout (live, isolation, lock out / tag out

  Yes

  No

  N/A

• Heavy equiptment lifting (cranes, boom trucks, excavators)

  Yes

  No

  N/A

• Entry into excavations/Trenches > 1.2 m (4ft) deep

  Yes

  No

  N/A

ensure all hazards identified are addressed in JSA below

• 1. sequence of basic job Step in order

• 1.potential hazards. (Ex. underground services, hazard zone etc.)

• 1.safety controls to reduce or eliminate hazard

• 2. sequence of basic job Step in order

• 2. potential hazards. (Ex. underground services, hazard zone etc.)

• 2. safety controls to reduce or eliminate hazard

• 3. sequence of basic job Step in order

• 3. potential hazards. (Ex. underground services, hazard zone etc.)

• 3.safety controls to reduce or eliminate hazard

• 4. sequence of basic job Step in order

• 4. potential hazards. (Ex. underground services, hazard zone etc.)

• 4.safety controls to reduce or eliminate hazard

• 5. sequence of basic job Step in order

• 5. potential hazards. (Ex. underground services, hazard zone etc.)

• 5.safety controls to reduce or eliminate hazard

additional PPE ( minimum requirement: safety boots, hard hat, visi-vest, glasses, gloves)

• Eye protection

  Yes

  No

  N/A

• Hearing protection

  Yes

  No

  N/A

• Fall protection

  Yes

  No

  N/A

• Rubber footwear and gloves if in a damp area

  Yes

  No

  N/A

• Protective gloves.

  Yes

  No

  N/A

• Full face shield.

  Yes

  No

  N/A

• Other (fire retardant coveralls, breathing apparatus, etc) specify :

Risk score before and after.

• Risk score before control measure

• Risk score after control measure.

• Risk Ranking Matrix

  

Local authorities:

• outside authorities

  Sign

disposal of designated substances, surplus, or impacted materials (disposal details, e.g when, where, how?)

• Add signature

  Sign

Service engineer/ technician

• prepared by

  Sign

• date

  Date

• person carrying out work

  Sign

• date

  Date

• person carrying out work

  Sign

• date

  Date

• person carrying out work

  Sign

• date

  Date

site supervisor

• JSA client signature

  Sign

• date

  Date