RHL Companies JSA report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date

  Date
• Where to meet in case of emergency:
  Address

• Contractor:

• Job # or Description of work to be performed:

• Designated Smoking Area Location:

• Facility/Well Name:

• GPS Coords for Emergencies:

• Contact:

Safety equipment required to do this job

• Hard Hat

• Steel Toe Boots

• Safety Glasses

• Hearing Protection

• Cotton/Rubber Gloves

• Face Shields/ Goggles

• Fire Extinguishers

• Lockout/Tagout

• Safety Harness/Anti-fall Device

• First Aid Kit

• Eye Wash

• Communications

• MSDS on site

• Helmets (ATV)

• Safety Vests

• Lights

• Other

Pre-Job Hazard Assessment

• Manual Lifting (Body Position)

  Safe

  At Risk

  N/A

• Mechanical Lifting Equipment

  Safe

  At Risk

  N/A

• Awkward Body Position

  Safe

  At Risk

  N/A

• Slip/Trip Potential

  Safe

  At Risk

  N/A

• Lifting w/Other Employees

  Safe

  At Risk

  N/A

• Proper Rigging Practices

  Safe

  At Risk

  N/A

• Handrails Placement

  Safe

  At Risk

  N/A

• Ladders/Stair Rails Placement

  Safe

  At Risk

  N/A

• Barricades Placed

  Safe

  At Risk

  N/A

• Secure Footing

  Safe

  At Risk

  N/A

• Evacuation Routes Identified

  Safe

  At Risk

  N/A

• Does work invoice Confined Space Entry?

  Safe

  At Risk

  N/A

• Has a Work Plan been developed?

  Safe

  At Risk

  N/A

• Proper Tool/Material Placement

  Safe

  At Risk

  N/A

• Hot/Cold Surface or Material

  Safe

  At Risk

  N/A

• Inadequate Lighting

  Safe

  At Risk

  N/A

• Fall Protection/Anchor Points

  Safe

  At Risk

  N/A

• Pinch Points

  Safe

  At Risk

  N/A

• Hand & Finger Hazards

  Safe

  At Risk

  N/A

• Electrical Hazards

  Safe

  At Risk

  N/A

• Welding/Flame Cutting

  Safe

  At Risk

  N/A

• Mechanical Equipment

  Safe

  At Risk

  N/A

• Road Gear & Derrick Locked & Tagged

  Safe

  At Risk

  N/A

• Are all containers properly labeled?

  Safe

  At Risk

  N/A

• Is H2S Present?

  Safe

  At Risk

  N/A

• Are simultaneous operations occurring on site?

  Safe

  At Risk

  N/A

• Have all operations been notified of work being performed?

  Safe

  At Risk

  N/A

• Does work invoice excavation, trenching, drilling etc?

  Safe

  At Risk

  N/A

• Has One Call Notification been made?

  Yes

  No

  N/A

• One Call Notification #:

• One Call Notification Date:

• Climbing

  Safe

  At Risk

  N/A

• Pulling, Pushing

  Safe

  At Risk

  N/A

• Bending

  Safe

  At Risk

  N/A

• Twisting Motion

  Safe

  At Risk

  N/A

• Walking

  Safe

  At Risk

  N/A

• Crawling

  Safe

  At Risk

  N/A

• Straining

  Safe

  At Risk

  N/A

• Stretching

  Safe

  At Risk

  N/A

• Reaching

  Safe

  At Risk

  N/A

• Over Extending

  Safe

  At Risk

  N/A

• Is a Hot Work Permit Required?

  Yes

  No

  N/A

• Does work require lockout tagout?

  Yes

  No

  N/A

• Sequence of Basic Job Steps

• Potential At-Risk Behaviors or Other Hazards

• Potential Hand and/or Finger Hazards

• Action Taken to Eliminate or Reduce Potential Hazards

Environmental Conditions

• Wind Speed and Direction:

• Weather:

• Light Conditions:

• Temperature:

• Surrounding Area Use

• Commercial

• Industrial

• Residential

• Farm/Ranch

• Other

• Supervision Availability

• None on Location

• Intermittent

• Foreman Pusher

• On Location

• Location

• Elevated

• Below Ground Level

• Confined Space

• Ground Level

• Type of Job

• Routine

• Medium

• Complex

• Work Area

• Open

• Tight

• Congested

• Communication During Task

• Written

• Verbal

• Hand Signal

• Intrinsically Safe Radio

• Other Service Companies on Location:

Crew Members, Company Representatives &Third Party Signatures

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• I have personally inspected the worksite & confirm that it is safe for the work described. (To be completed by the Responsible Person on the job site)

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• I have personally inspected the worksite & confirm that it is safe for the work described. (To be completed by the Responsible Person on the job site)

  Sign

• I have personally inspected the worksite & confirm that it is safe for the work described. (To be completed by the Responsible Person on the job site)

  Sign

• I have personally inspected the worksite & confirm that it is safe for the work described. (To be completed by the Responsible Person on the job site)

  Sign

• I have personally inspected the worksite & confirm that it is safe for the work described. (To be completed by the Responsible Person on the job site)

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