Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • LOCATION

  • JOB NUMBER

  • DATE AND TIME

  • NAME OF PERSON COMPLETING JSA

  • CONDITIONS OF SURFACES

  • WORK AREA / WALKWAYS CLEAN AND FREE OF OBSTACLES, DERBIES AND HAZARDS

  • HAVE MANUAL HANDLING TASKS BEEN TAKEN INTO CONSIDERATION?

  • HAS VEHICLE COLLISION BEEN CONSIDERED?

  • HAVE ACTIVITIES AND PERSONS IN OR. EAR WORK AREA BEEN TAKEN INTO CONSIDERATION?

  • NOISE LEVELS?

  • ENVIRONMENTAL HAZARDS TAKEN INTO CONSIDERATION? - contamination to earth,air or water

  • ARE ALL WORKERS INDUCTED TO SITE AND FIT FOR WORK

  • POSSIBILITY OF SNAKES, SPIDERS, VERMIN AND OTHER WILDLIFE TAKEN INTO CONSIDERSTION?

  • ELECTRICAL HAZARDS TAKEN INTO CONSIDERATION?

  • ALL ELECTRICAL EQUIPMENT TO BE TESTED AMD TAGGED WITH GUARDS IN PLACE AND OVERALL GOOD CONDITION?

  • PPE CORRECT FOR TASK IN GOOD CONDITION AND PROPERLY WORN?

  • AIRBORNE CONTAMINANTS TAKEN INTO CONSIDERATION?

  • FUMES AND GASES TAKEN INTO CONSIDERATION?

  • WEATHER CONDITIONS CONSIDERED? - rain, sun, heat etc

  • IS LIGHTING SUITABLE FOR TASK?

  • IS VENTILATION ADEQUATE?

  • HAZARDOUS SUBSTANCES AND DANGERS GOODS SDS SHEETS AND RISK ASSESSMENTS READILY AVAILABLE?

  • DOES THE TASK INVOLVE A CONFINED SPACE PERMIT? - If yes please include more information below

  • CONFINED SPACE DETAILS

  • PHOTO OF PERMIT

  • DOES THE TASK REQUIRE A HOT WORKS PERMIT? - If yes please include more information below

  • HOT WORKS PERMIT DETAILS

  • PHOTO OF PERMIT

  • DOES THE TASK REQUIRE A WORK AT HEIGHTS PERMIT? - If yes please include more information below

  • WORK AT HEIGHTS PERMIT DETAILS

  • PHOTO OF PERMIT

  • ARE THERE ANY ADDITIONAL HAZARDS?

  • LIST ADDITIONAL HAZARDS

  • LIST ADDITIONAL CONTROLS

  • LIST JOB STEPS IN SEQUENCE

  • RELEVANT PHOTO

  • RELEVANT PHOTO

  • ALL PERSONS TO SIGN ONTO JSA

  • NAME AND SIGN

  • NAME AND SIGN

  • NAME AND SIGN

  • NAME AND SIGN

  • SAFETY SCORE

  • RISK ASSESSMENT MATRIX

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