Title Page
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Date:
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Job Description:
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Job No:
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Customer/Client/Contract:
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Location
Site Supervisor
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Name:
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NAME:
EMERGENCY RESPONSE INFORMATION:
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Supervisor
- Ross Kronfeld-027 667 3760
- Andrew Carter-027-222-3341
- Gary Oliver-027-355-6131
- Paul Soffe-027 299 9020
- Allan Richards-027 603 0999
- Jason Gibbs-027 445 4336
- Kate Fitzgerald-027 276 4308
- Ted Glasgow-021 981 016
- Mike Thompson-027 445 4195
- Thomas Tanoa-027 555 2797
- Albert Rodrigues-027 742 8365
- Ben Hills-027 555 4177
- Greg McCutchan-027 269 0337
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Branch Phone:
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EMERGENCY SERVICES: 111
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First Aid Kit
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Fire Extinguisher
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Spill Kit Location
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Height Rescue Kit
Hazards / Risks
Permit Requirements
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Permits Required
- None
- Confined Space
- Excavation
- Hot Work
- Isolation/Electrical
- HV NAPA
- LV NAPA
- Live LV Permit
- Other
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Please Specify
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Critical Risks Activities to consider
- Driving
- Working at height
- Working Near Live Electricity
- Working with or near Mobile Plant
- Hazardous Substances
- Working around others
- Manual Handing
- Cranes & Lifting
- Working with or near Traffic
- Working around Underground Services
- Working Alone
- Confined Space Work
Step 1 -Planning
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Are there any hazards associated with this step?
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Identify Hazards
- Scope of work not identified
- No authorization to work
- Client notification not completed
- Resources unavailable
- Incorrect job information
- Other
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Initial risk assessment
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Controls
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Residual risk assessment
Step 2- Site Setup
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Are there any hazards associated with this step?
- Yes
- No
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Identify Hazard
- Roles and responsibilities not assigned
- Inexperienced workers
- Inadequate traffic management
- Work area not defined
- Other PCBU's
- Public
- Visitors
- Not signed onto site
- Other
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Initial risk assessment
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Controls
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Residual risk assessment
Step 3- During the work
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Are there any hazards associated with this step?
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Identify Hazards
- Traffic
- Height Work
- Electricity
- Mobile Plant
- Hazardous Substances
- Others
- Manual Handling
- Lifting operations
- Underground services
- Lone working
- Confined spaces
- Other
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Initial risk assessment
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Controls
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Residual risk assessment
Step 4- Site disestablishment
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Are there any Hazards associated with this step?
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Identify Hazards
- Traffic
- Height Work
- Electricity
- Mobile Plant
- Hazardous Substances
- Others
- Manual Handling
- Lifting operations
- Underground services
- Lone working
- Confined spaces
- Other
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Initial risk assessment
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Controls
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Residual risk assessment
Step 5- Job completion / Quality Assurance
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Identify Hazards
- Unfinished work
- Incomplete job notes
- Incorrect test results
- Incorrect As-builts
- Incomplete Certification
- Permits not closed out/returned
- Defects not reported
- Other
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Initial risk assessment
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Controls
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Residual risk assessment
Changing Conditions
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Identify changes in the workplace
- None
- Change of site?
- Job methodology?
- Site supervision?
- Resources: people /equipment / time?
- Weather conditions ?
- Other contractors?
- Site controls?
- Other
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Initial risk assessment
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Controls
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Residual risk assessment
Risk assessment matrix
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Risk assessment matrix
Sign Off
Job Safety and Environmental Analysis Work Team Sign-On
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The undersigned acknowledge that they have been consulted in respect to the hazards of the job and how the job is to be completed safely, that they have read, understood and will adhere to the requirements of this JSEA. Any changes to hazards, conditions, work environment or job steps requires modification of the JSEA and communication of changes.
Work Team and Visitor Sign-On
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Daily Sign On / Off
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Date
Name
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Team Member / Visitor
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Sign On
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Sign Off
Sign on
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Name
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Sign On
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Sign Off
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Name
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Sign On
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Sign Off
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Name
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Sign On
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Name
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Sign Off
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Name
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Sign On
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Sign Off
