WES 3.2 JOB SAFETY ANALYSIS (JSA) FORM

• Project Number

• Client / Site

• Conducted on

  Date

• Prepared by

1.0 check applicable anticipated or potential hazards

• Activities in or near traffic areas

  Safe

  At Risk

  N/A

• Live Electrical work, including high test voltages or current

  Safe

  At Risk

  N/A

• Lifting heavy objects

  Safe

  At Risk

  N/A

• Other (specify) :

  Safe

  At Risk

  N/A

2.0 critical procedures: where work involves any of the following hazards must be incorporated into JSA

• Work at heights above 6ft

  Safe

  At Risk

  N/A

• Confined space entry

  Safe

  At Risk

  N/A

• Electrical/Mechanical lockout (live, isolation, lock out / tag out

  Yes

  No

  N/A

3.0 Training Requirements

• OSHA Safety and Health

  Yes

  No

  N/A

• MSHA Safety and Health

  Yes

  No

  N/A

• CPR and First Aid

  Yes

  No

  N/A

• Site Specific

  Yes

  No

  N/A

4.0 Site Safety Checklist

• Safe Ladder procedures

  Yes

  No

  N/A

• Hazardous Materials - MSDS

  Yes

  No

  N/A

• Lockout / Tagout

  Yes

  No

  N/A

• Grounding Procedures

  Yes

  No

  N/A

• Condition of tools & cords

  Yes

  No

  N/A

• First Aid Station / Hospital location

  Yes

  No

  N/A

• Fire extinguisher location

  Yes

  No

  N/A

• Strap & Tie down safety checks

  Yes

  No

  N/A

5.0 Tools / Equipment ( list of tools and equipment and their storage on site

• List

  Yes

  No

  N/A

6.0 Personal Protective Equipment

• Hard Hat, eye protection, safety boots required?

  Yes

  No

  N/A

• Hearing protection required?

  Yes

  No

  N/A

• Fall protection required?

  Yes

  No

  N/A

• Fire Retardant clothing required?

  Yes

  No

  N/A

• High Visibility Vest required?

  Yes

  No

  N/A

• Portable gas monitor required?

  Yes

  No

  N/A

• Breathing Apparatus required?

  Yes

  No

  N/A

• Other

7.0 Waste disposal

8.0 Client Representative

• Client Representative (when required)

  Sign

9.0 Site Personnel

• List all WES personnel onsite

• JSA approved

  Sign

• date

  Date