Roofing JSA FORM - DCC

• Client/Site

• Document No.

• Project Description

• Conducted on

  Date

• Prepared by

• Location
  Address

site information

• Forman

• Project Manager

check applicable anticipated or potential hazards

• Demolition/Tear-off

  Safe

  At Risk

  N/A

• Chemicals

  Safe

  At Risk

  N/A

• What Chemicals

• Activities in or near traffic areas

  Safe

  At Risk

  N/A

• Environmental Hazards (Hot, Cold, Wind)

  Safe

  At Risk

  N/A

• Other (specify) :

  Yes

  No

  N/A

critical procedures: where work involves any of the following hazards must be incorporated into JSA

• Electrical/Mechanical lockout (live, isolation, lock out / tag out

  Yes

  No

  N/A

• Potential Hazards

• Safety Controls

• Heavy equiptment lifting (cranes, boom trucks, excavators)

  Yes

  No

  N/A

• Potential Hazards

• Safety Controls

• Hot work (in potentially explosive atmosphere)

  Yes

  No

  N/A

• Potential Hazards

• Safety Controls

ensure all hazards identified are addressed in JSA below

• Set up Job

• Type of Fall Protection

  Select Cable system Flagging Roof Monitor PFAS Other

  • Cable system
  • Flagging
  • Roof Monitor
  • PFAS
  • Other

• Type if 'other'

• installed correctly, when removed use PFAS

• 6ft from edge, flagging stays tight, when removed use PFAS

• Roof monitor has no other job and is on the same level

• Anchors can hold 5000lbs, system is not overloaded, all parts have been inspected

• Type of Access

  Ladder

  Scaffold

  Stairs

• At 4 to1 angle, 4 rungs above the platform, tied off

• Scaffold inspected and has top rail, mid rail and toe board

• Use handrails, no horseplay

• 1. Tear Off

  Yes

  No

  N/A

• Potential Hazards

• Safety Controls

• 2. Deck Replacement

  Yes

  No

  N/A

• Potential Hazards

• Safety Controls

• 3. Install new system

  Yes

  No

  N/A

• Potential Hazards

• Safety Controls

• Clean up

  Yes

  No

  N/A

• Pick up all trash, roll up cords, secure loose items, do final walk to make sure area is clean

• Watch for slip, trip, fall hazards, when removing fall protection keep minimum employees on roof and they must stay 6ft from the edge.

• Other

Emergency Protocols

• Evacuation procedure

• Tornado procedure

• In case of fire

• Off site Medical

  Yes

  No

  N/A

• Urgent Care

• Hospital

• In case of fall

additional PPE ( minimum requirement: safety boots, hard hat, visi-vest, glasses, gloves)

• Eye protection

• What kind

• Hearing protection

• Fall protection

• Other specify :

Signatures

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• Project Manager

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• Foreman

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