Title Page
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Conducted on
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Prepared by
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Site Location
Project Description or Work Order
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Please provide an overview of the project and type of work or provide the work order if applicable:
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Provide a site photo
Potential Hazards and Hazard Elimination Strategies
Tasks
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List the tasks required for this project:
Identify Potential Hazards
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Choose all potential hazards that apply.
- Trips/Slips/Falls
- Soft Tissue Injuries
- Particles in the eye
- Overexertion
- Falls over 4'
- Overhead work
- Sprains/Strains
- Fire
- Abrasion/Cuts
- Cave-in
- Loud Noises
- Heat/Cold Exposure
- Electric Shock
- Pinch Points
- Lead/Asbestos
- Moving Machinery
- Live Utilities
- Working with Chemicals
- Spills
- Tools/Materials
- Dropping to a Level
- Chemical Burn
- Elevated Load
- Blind Spots
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Add photos
Identify Hazard Elimination Strategies
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Chose all hazard elimination strategies that will be utilized.
- Keep area picked up
- Stretch and bend
- Face shield/goggles
- Get additional help
- Fall protection
- Toeboards/Netting
- Lift/Carry Properly
- Fire Watch/Fire Ext.
- Wear Proper Clothing
- Sloping/Shoring
- Hearing Protection
- Dress Appropriately
- Cords/ Tools Inspected
- Be in Proper Position
- Get safety involved/additional guidance
- Review the SDS
- Add Containment
- Specialized tools or materials
- Gloves or protective clothing
- Proper rigging/taglines
- Use spotters for blind spots
Any Additional Instructions
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Add special or additional instructions here:
Weather
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Note current weather conditions
Tools and Equipment Required
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List all tools and equipment required
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Verify all employees have received proper training
Permits, Inspections and other forms required
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Choose all that are required
- Ground Disturbance (PA One Call)
- Hot Work Permit
- Scaffold Inspection (daily)
- Aerial Lift Inspection (preshift)
- Forklift, any type (preshift)
- Confined Space Permit
- Energized Electrical Work Permit
- Trench Inspection (pre-entry)
- Vehicle Pre-trip Inspection (preshift)
- None
- Other, please add in notes section
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I will complete the necessary permit or inspection and will adhere to the permit or procedure as required.
Crew Members
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Print and sign here acknowledging the JSA has been reviewed.
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Add signature
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Add signature
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Add signature
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Add signature
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