SS JSA

• Client:

• Client Location Address
  Address

• Client Contact

• Client Contact Phone Number

• Unit:

• Job/Work Order #

• Completed By:

• Job Lead / Site Supervisor:

• Date / Time:

  Date

Type of Job / Job Scope

• Heat Treat Services

• Fab / Weld

• Shop Work

• Other

• Brief Description of Work Task

• Has pre-job walk down/ assessment been performed?

  Yes

  No

• If the pre-job walk down/assessment has not been performed then do not proceed until it has been conducted.

• Emergency Phone Number(s)

• Location of First Aid Station/Supplies:

• Primary e=Evacuation l=Location:

• Secondary Evacuation Location:

• Shelter In Place Location:

• Nearest Fire Extinguisher Location:

• Nearest Safety Shower/Eye Wash Location:

• Wind Direction:

  Select North North East East South East South South West West North West

  • North
  • North East
  • East
  • South East
  • South
  • South West
  • West
  • North West

• Equipment Emergency Shutdown Procedures

• Does the job require a critical work review?

  Yes

  No

  N/A

• Critical Job #

Nuclear Status

• Nuclear Safety Related

  Yes

  No

  N/A

• Nuclear

  Yes

  No

  N/A

• Non-Safety

  Yes

  No

  N/A

• Non-Nuclear

  Yes

  No

  N/A

• Briefly describe each specific hazard & control method

• 1) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 2) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 3) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 4) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 5) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 6) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 7) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 8) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 9) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 10) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 11) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 12) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 13) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 14) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 15) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 16) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 17) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 18) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 19) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

• 20) Sequence of Basic Job Step

• Identify Potential Hazards

• Controls to Reduce and/or Eliminate Hazards

Permitting

• Work permits required?

  Yes

  No

  N/A

• Permit type

• Permit Number

• Permit requirements identified and reviewed by permit issuer and crew personnel?

  Yes

  No

• All required signatures obtained on permit?

  Yes

  No

Potential Heat/Cold Stress Hazards

• Are appropriate fluids available?

  Yes

  No

  N/A

• Stop JSA and do not proceed with job until appropriate fluids are made available! Once fluids are made available revise answer and move forward with JSA and job.

• Are work rest cycles established?

  Yes

  No

  N/A

• Is adequate clothing being worn?

  Yes

  No

  N/A

Power Tools

• Are power tools or grinders being used?

  Yes

  No

  N/A

• Eye and face protection available and being used?

  Yes

  No

  N/A

• Shirt tails tucked in, no loose clothing?

  Yes

  No

  N/A

• All equipment guards in place as per manufacture requirements?

  Yes

  No

  N/A

• Proper hand placement/body position?

  Yes

  No

  N/A

• Tools and electrical cords inspected prior to use?

  Yes

  No

  N/A

• Color coded as per policy?

  Yes

  No

  N/A

Line of Fire Hazards

• Is there a potential for line of fire hazards?

  Yes

  No

  N/A

• All crew members aware to not stand in front of or under moving loads?

  Yes

  No

  N/A

• Discussed operation path of tools or equipment on site with crew members?

  Yes

  No

  N/A

• Assessed proper body, hand; or head position prior to starting task?

  Yes

  No

  N/A

Slips, Trips, and Falls

• Is there a potential for slips, trips or falls?

  Yes

  No

  N/A

• Have hazardous areas been barricaded?

  Yes

  No

  N/A

• Tools and equipment out of walking paths?

  Yes

  No

  N/A

• Snow and ice removed?

  Yes

  No

  N/A

• Wet/slippery walkways cleaned up or able to be avoided?

  Yes

  No

  N/A

• Cords or hoses out of walkways routed out of walkways?

  Yes

  No

  N/A

Elevated Work Activities

• Will there be any elevated work activities?

  Yes

  No

  N/A

• Has overhead work been addressed with everyone working in the area?

  Yes

  No

  N/A

• Dropped object prevention reviewed?

  Yes

  No

  N/A

• Work areas below barricaded off?

  Yes

  No

  N/A

• Proper lifting devices used for lifting equipment?

  Yes

  No

  N/A

Hand Hazards

• Is there a potential for hand hazards?

  Yes

  No

  N/A

• What level of hand protection is needed?

• Leather

  Yes

  No

  N/A

• Chemical/Rubber

  Yes

  No

  N/A

• Impact/Cut Resistant

  Yes

  No

  N/A

• Hot/Cold Protection

  Yes

  No

  N/A

Additional Work Area Hazards

• Are there any additional work area hazards?

  Yes

  No

  N/A

• Area assessed for other personnel working in close proximity (hot work, electrical, ect.)

  Yes

  No

  N/A

• Operating equipment assessed?

  Yes

  No

  N/A

• Overhead work being done around work area assessed?

  Yes

  No

  N/A

• Other work area hazards?

Working at Heights

• Will any crew members be working at heights?

  Yes

  No

  N/A

• Communication methods for employees working at heights.

  Visual/Hand Signals

  Radio

  Verbal/ No Radio

  Other

• Scaffold Inspected & tagged by Competent Person?

  Yes

  No

  N/A

• Inspection Date?

  Date

• Scaffold tag color?

  Select Red - Do not use Yellow - Fall protection 100% tie off at all times Green - Use as per policy requirements

  • Red - Do not use
  • Yellow - Fall protection 100% tie off at all times
  • Green - Use as per policy requirements

• Are ladders being utilized?

  Yes

  No

• Ladder inspected prior to use?

  Yes

  No

• Ladder secured to prevent movement?

  Yes

  No

• Are aerial platforms such as Forklift with secured basket, JLG, Scissor Lift, etc. being used?

  Yes

  No

• Is the operator certified?

  Yes

  No

Respiratory Protection

• Yes

  No

  N/A

Confined Space Entry

• Yes

  No

  N/A

Crane Operations

• Yes

  No

  N/A

Compressed Gasses

• Yes

  No

  N/A

Personal Protective Equipment

• Yes

  No

  N/A

Emergency Action Plan

• Yes

  No

  N/A

Acknowledgement Signatures

• I acknowledge reviewing this JSA and understand my duty to enforce "Stop Work Responsibility" if conditions change and/or when the job be-comes unsafe. As work shift progresses; I shall revisit the JSA when new hazards become present and/ or when the job scope changes. I also confirm that I am mentally engaged and fit for duty to perform the task.

  Sign

• I acknowledge reviewing this JSA and understand my duty to enforce "Stop Work Responsibility" if conditions change and/or when the job be-comes unsafe. As work shift progresses; I shall revisit the JSA when new hazards become present and/ or when the job scope changes. I also confirm that I am mentally engaged and fit for duty to perform the task.

  Sign

• I acknowledge reviewing this JSA and understand my duty to enforce "Stop Work Responsibility" if conditions change and/or when the job be-comes unsafe. As work shift progresses; I shall revisit the JSA when new hazards become present and/ or when the job scope changes. I also confirm that I am mentally engaged and fit for duty to perform the task.

  Sign

• I acknowledge reviewing this JSA and understand my duty to enforce "Stop Work Responsibility" if conditions change and/or when the job be-comes unsafe. As work shift progresses; I shall revisit the JSA when new hazards become present and/ or when the job scope changes. I also confirm that I am mentally engaged and fit for duty to perform the task.

  Sign

• I acknowledge reviewing this JSA and understand my duty to enforce "Stop Work Responsibility" if conditions change and/or when the job be-comes unsafe. As work shift progresses; I shall revisit the JSA when new hazards become present and/ or when the job scope changes. I also confirm that I am mentally engaged and fit for duty to perform the task.

  Sign

• I acknowledge reviewing this JSA and understand my duty to enforce "Stop Work Responsibility" if conditions change and/or when the job be-comes unsafe. As work shift progresses; I shall revisit the JSA when new hazards become present and/ or when the job scope changes. I also confirm that I am mentally engaged and fit for duty to perform the task.

  Sign

• I acknowledge reviewing this JSA and understand my duty to enforce "Stop Work Responsibility" if conditions change and/or when the job be-comes unsafe. As work shift progresses; I shall revisit the JSA when new hazards become present and/ or when the job scope changes. I also confirm that I am mentally engaged and fit for duty to perform the task.

  Sign

• I acknowledge reviewing this JSA and understand my duty to enforce "Stop Work Responsibility" if conditions change and/or when the job be-comes unsafe. As work shift progresses; I shall revisit the JSA when new hazards become present and/ or when the job scope changes. I also confirm that I am mentally engaged and fit for duty to perform the task.

  Sign

JSA Revision

• Did the JSA have to be revised

  Yes

  No

• Employee Signature for Revision

  Sign

• Employee Signature for Revision

  Sign

• Employee Signature for Revision

  Sign

• Employee Signature for Revision

  Sign

• Employee Signature for Revision

  Sign

• Employee Signature for Revision

  Sign

• Employee Signature for Revision

  Sign

• Employee Signature for Revision

  Sign

Supervisor/Lead Technician Completion Signature

• Have all permits been closed out?

  Yes

  No

• Was Stop Work Authority exercised during the job?

  Yes

  No

• Has the job been cleaned of any trash or debris?

  Yes

  No

• I acknowledge that all job task were performed safely and without incident or injury.

  Sign