Title Page
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Select date
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Prepared by
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Manager Name
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Location
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Audit Title
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Client / Site
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Personnel
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1st Job Task
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Potential Hazards?
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Controls to Mitigate Hazards / Remove
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2ND Job Task
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Potential Hazards?
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Controls to Mitigate Hazards / Remove
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3rd Job Task
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Potential Hazards?
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Controls to Mitigate Hazards / Remove
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4th Job Task
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Potential Hazards?
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Controls to Mitigate Hazards / Remove
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5th Job Task
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Potential Hazards?
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Controls to Mitigate Hazards / Remove
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6th Job Task
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Potential Hazards?
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Controls to Mitigate Hazards / Remove
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7th Job Task
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Potential Hazards?
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Controls to Mitigate Hazards / Remove
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PPE - Safety Glasses?
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PPE - LOTO Gear?
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PPE - Face Shield
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PPE - FR Clothing?
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PPE - Steel Toe Boots?
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PPE - HARD HAT?
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PPE - Fall Protection Kit?
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PPE - Hearing Protection?
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PPE - Electrical Rubber Gloves Class O? 1000W?
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PPE - Welding Gloves
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PPE - Leather Gloves
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PPE - Other
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PPE - Other
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PPE - Other
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Employees are annually trained in all required PPE?
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I understand and will adhere to the steps, Hazards, & Controls as described in this JSA. I understand that performing steps out of sequence may pose hazards that have note been evaluated, not authorized. I will contact my supervisor prior to continuing work, if the scope of work changes or new hazards are introduced. I understand I have the authority and the responsibility to stop work I believe to be unsafe.
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I the below signed Supervisor have read and understand all steps and hazards and will see to the mitigation of these small other hazards.
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I the site Project Manager / Superintendent have communicated read and authorize the listed workers to perform work for this activity and have coordinated the described activity with effected occupants. The above listed workers are released to perform described scope of work.
