Title Page

  • Conducted on

  • Prepared by

  • Site Location

Project Description or Work Order

  • Please provide an overview of the project and type of work or provide the work order if applicable:

  • Provide a site photo

Potential Hazards and Hazard Elimination Strategies

Tasks

  • List the tasks required for this project:

Identify Potential Hazards

  • Choose all potential hazards that apply.

  • Add photos

Identify Hazard Elimination Strategies

  • Chose all hazard elimination strategies that will be utilized.

Any Additional Instructions

  • Add special or additional instructions here:

Weather

  • Note current weather conditions

Tools and Equipment Required

  • List all tools and equipment required

  • Verify all employees have received proper training

Permits, Inspections and other forms required

  • Choose all that are required

  • I will complete the necessary permit or inspection and will adhere to the permit or procedure as required.

Crew Members

  • Print and sign here acknowledging the JSA has been reviewed.

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

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.