Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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LOCATION
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JOB NUMBER
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DATE AND TIME
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NAME OF PERSON COMPLETING JSA
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CONDITIONS OF SURFACES
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WORK AREA / WALKWAYS CLEAN AND FREE OF OBSTACLES, DERBIES AND HAZARDS
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HAVE MANUAL HANDLING TASKS BEEN TAKEN INTO CONSIDERATION?
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HAS VEHICLE COLLISION BEEN CONSIDERED?
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HAVE ACTIVITIES AND PERSONS IN OR. EAR WORK AREA BEEN TAKEN INTO CONSIDERATION?
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NOISE LEVELS?
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ENVIRONMENTAL HAZARDS TAKEN INTO CONSIDERATION? - contamination to earth,air or water
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ARE ALL WORKERS INDUCTED TO SITE AND FIT FOR WORK
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POSSIBILITY OF SNAKES, SPIDERS, VERMIN AND OTHER WILDLIFE TAKEN INTO CONSIDERSTION?
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ELECTRICAL HAZARDS TAKEN INTO CONSIDERATION?
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ALL ELECTRICAL EQUIPMENT TO BE TESTED AMD TAGGED WITH GUARDS IN PLACE AND OVERALL GOOD CONDITION?
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PPE CORRECT FOR TASK IN GOOD CONDITION AND PROPERLY WORN?
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AIRBORNE CONTAMINANTS TAKEN INTO CONSIDERATION?
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FUMES AND GASES TAKEN INTO CONSIDERATION?
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WEATHER CONDITIONS CONSIDERED? - rain, sun, heat etc
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IS LIGHTING SUITABLE FOR TASK?
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IS VENTILATION ADEQUATE?
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HAZARDOUS SUBSTANCES AND DANGERS GOODS SDS SHEETS AND RISK ASSESSMENTS READILY AVAILABLE?
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DOES THE TASK INVOLVE A CONFINED SPACE PERMIT? - If yes please include more information below
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CONFINED SPACE DETAILS
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PHOTO OF PERMIT
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DOES THE TASK REQUIRE A HOT WORKS PERMIT? - If yes please include more information below
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HOT WORKS PERMIT DETAILS
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PHOTO OF PERMIT
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DOES THE TASK REQUIRE A WORK AT HEIGHTS PERMIT? - If yes please include more information below
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WORK AT HEIGHTS PERMIT DETAILS
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PHOTO OF PERMIT
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ARE THERE ANY ADDITIONAL HAZARDS?
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LIST ADDITIONAL HAZARDS
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LIST ADDITIONAL CONTROLS
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LIST JOB STEPS IN SEQUENCE
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RELEVANT PHOTO
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RELEVANT PHOTO
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ALL PERSONS TO SIGN ONTO JSA
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NAME AND SIGN
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NAME AND SIGN
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NAME AND SIGN
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NAME AND SIGN
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RISK ASSESSMENT MATRIX