• Customer

  • Conducted on

  • 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?

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

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

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

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

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

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

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

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

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

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


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

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


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


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


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


  • As applicable, is Meet and Greet properly supported?


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

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

  • Additional comments

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

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

  • Auditor signature.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.