US PACIFIC AREA JSA ASSESSMENT FORM

• Customer

• Conducted on

  Date

• Auditor

• Well Number / Location

• Product Line

• Note: Any no answers require a comment in the text field under the appropriate section.

Job Planning

• Is all required information complete, accurate and legible?

  Yes

  No

  N/A

• Is the JSA written for the specific task the crew is performing?

  Yes

  No

  N/A

• Does the JSA identify obvious hazards that could lead to an accident, injury or illness?

  Yes

  No

  N/A

• Are hazards identified on the Task Hazard Assessment and managed (eliminated, controlled or mitigated) on the JSA?

  Yes

  No

  N/A

• Was the hazard See-it wheel used in creating the JSA?

  Yes

  No

  N/A

• Does the JSA address the specific PPE required for the hazards listed?

  Yes

  No

  N/A

• Does the JSA address the hazards of the tools and equipment being used?

  Yes

  No

  N/A

• Does the JSA address appropriate body position, Safety In Motion techniques and "line of fire" issues?

  Yes

  No

  N/A

• Does the JSA clearly identify (names) SSEs and mentors, if applicable?

  Yes

  No

  N/A

• If required, did the team make changes to an existing work procedure or practice for site specific Hazards or change in scope?

  Yes

  No

  N/A

• Have the recommended mitigation actions and /or procedures been put into place? (On site assessments only)

  Yes

  No

  N/A

Communication

• Are all employees on site aware of where they are on the JSA and referenced SOP's?

  Yes

  No

  N/A

• Have other contract workers been involved in sharing as appropriate?

  Yes

  No

  N/A

Scope

• Do employees understand the steps until the next natural break?

  Yes

  No

  N/A

SOPs

• If there are required references identified (e.g. Procedures, etc.), are these documents attached to the JSA or otherwise readily available?

  Yes

  No

  N/A

PTW

• Are all required Permit to Work documents current, signed and attached to the job plan?

  Yes

  No

  N/A

Security

• As applicable, is Meet and Greet properly supported?

  Yes

  No

  N/A

Debrief

• Are employees prepared to support the debrief at the end of the job?

  Yes

  No

  N/A

• Are you satisfied with the overall quality of the JSA?

  Yes

  No

  N/A

• Additional comments

• *Note: Form can not be submitted until feedback has been completed.

• Did you provide feedback to the crew on your assessment?

  Yes

  No

  N/A

• Auditor signature.

  Sign