STRUCTURAL JSA Check

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Job Details

• Is the Job Number/Name identified?

  Yes

  No

  N/A

• Is the Unit/Equipment Number identified?

  Yes

  No

  N/A

• Is the permit type listed?

  Yes

  No

  N/A

• Is the job contact identified?

  Yes

  No

  N/A

• Is the location of the eye wash station listed?

  Yes

  No

  N/A

• Have the primary and secondary assembly areas been identified?

  Yes

  No

  N/A

• Are emergency numbers listed?

  Yes

  No

  N/A

• Has the wind direction been identified?

  Yes

  No

  N/A

• Has the first aid station been located?

  Yes

  No

  N/A

• Is the job description listed?

  Yes

  No

  N/A

PPE

• Has the proper PPE been identified and listed on the JSA?

  Yes

  No

  N/A

Safety Equipment/ Resources

• Has the safety equipment been identified and listed on the JSA?

  Yes

  No

  N/A

Work Permit

• Are all Work Permits listed?<br>

  Yes

  No

  N/A

Signatures

• Has each member of the crew signed?

  Yes

  No

  N/A

• Has the Foreman signed off for the JSA completion?

  Yes

  No

  N/A

TOTAL 'YES' OUT OF 14

• Total number of 'Yes' answers to the completion of each section

• On site representative's signature

  Sign

• Auditor's signature

  Sign