Sample - JOB SAFETY ANALYSIS (JSA) FORM

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

site information

• work order number

• task activity

• date

  Date

• Site number/Name

• name of contractor/Subcontractor

check applicable anticipated or potential hazards

• Demolition

  Safe

  At Risk

  N/A

• Underground tank removal/Disposable/High vapors

  Safe

  At Risk

  N/A

• Activities in or near traffic areas

  Safe

  At Risk

  N/A

• Concrete cutting or coring

  Safe

  At Risk

  N/A

• Mobile heavy equipment activity (excavators, dump trucks, vacuum and hydovac trucks)

  Safe

  At Risk

  N/A

• Pile driving / shoring

  Safe

  At Risk

  N/A

• Work affecting integrity of critical controls

  Safe

  At Risk

  N/A

• Welding, cutting, grinding

  Yes

  No

  N/A

• Hydoblasting / sand blasting

  Yes

  No

  N/A

• Radiography / X-Ray testing

  Yes

  No

  N/A

• pressure testing

  Yes

  No

  N/A

• Other (specify) :

  Yes

  No

  N/A

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

• Work at heights above 1.5m

  Yes

  No

  N/A

• Confined space entry (includes tank cleaning)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Drilling borehole / excavations (Sub-surface clearance, locates)

  Yes

  No

  N/A

• Entry into excavations/Trenches > 1.2 m (4ft) deep

  Yes

  No

  N/A

• Hot work (in potentially explosive atmosphere)

  Yes

  No

  N/A

ensure all hazards identified are addressed in JSA below

• 1. sequence of basic job Step in order

• 1.potential hazards. (Ex. underground services, hazard zone etc.)

• 1.safety controls to reduce or eliminate hazard

• 2. sequence of basic job Step in order

• 2. potential hazards. (Ex. underground services, hazard zone etc.)

• 2. safety controls to reduce or eliminate hazard

• 3. sequence of basic job Step in order

• 3. potential hazards. (Ex. underground services, hazard zone etc.)

• 3.safety controls to reduce or eliminate hazard

• 4. sequence of basic job Step in order

• 4. potential hazards. (Ex. underground services, hazard zone etc.)

• 4.safety controls to reduce or eliminate hazard

• 5. sequence of basic job Step in order

• 5. potential hazards. (Ex. underground services, hazard zone etc.)

• 5.safety controls to reduce or eliminate hazard

tools / Equipment ( list of tools and equipment and their storage on site, if relevant to safety

• List

  Yes

  No

  N/A

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

• Eye protection

  Yes

  No

  N/A

• Hearing protection

  Yes

  No

  N/A

• Fall protection

  Yes

  No

  N/A

• Rubber footwear and gloves if in a damp area

  Yes

  No

  N/A

• Portable gas monitor

  Yes

  No

  N/A

• Other (fire retardant coveralls, breathing apparatus, etc) specify :

outside authorities:

• undefined

• outside authorities

  Sign

disposal of designated substances, surplus, or impacted materials (disposal details, e.g when, where, how?)

• undefined

• Add signature

  Sign

retailer/Sales associate

• prepared by

  Sign

• date

  Date

• person carrying out work

  Sign

• date

  Date

• person carrying out work

  Sign

• date

  Date

• person carrying out work

  Sign

• date

  Date

site supervisor

• JSA approved retailer/Sales associate signature

  Sign

• date

  Date