Job Safety Analysis (JSA) Form

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Job Safety Analysis (JSA) Form

Information regarding site

number of work order

task activity

date

Select date

Site number or name

name of contractor or subcontractor

Check applicable, anticipated or potential hazards

Underground tank removal/Disposable/High vapors

Safe At Risk N/A

Demolition

Safe At Risk N/A

Activities in/ near traffic areas

Safe At Risk N/A

Concrete cutting/ coring

Safe At Risk N/A

Mobile heavy equipment activities (excavators, dump trucks, vacuum and hydrovac trucks)

Safe At Risk N/A

Pile driving or shoring

Safe At Risk N/A

Work which affects integrity of critical controls

Safe At Risk N/A

Welding, cutting or grinding

Yes No N/A

Hydroblasting or sand blasting

Yes No N/A

Radiography or X-Ray testing

Yes No N/A

pressure testing

Yes No N/A

Other (please specify) :

Yes No N/A

critical procedures: when work involves any of these hazards it must be incorporated into JSA

Work at heights above 1,5m

Yes No N/A

Confined space entry (also during tank cleaning)

Yes No N/A

Electrical/Mechanical lockouts (live, lock out / tag out, isolation,)

Yes No N/A

Heavy equiptment lifting (cranes, excavators, boom trucks)

Yes No N/A

Drilling borehole or excavations (locates, sub-surface clearance)

Yes No N/A

Entry into excavations/Trenches: 1,2m deep

Yes No N/A

Hot work (in possibly explosive atmospheres)

Yes No N/A

Make sure that all hazards identified are addressed in JSA below

(A) sequence of basic job steps in order

(A) potential hazards (e.g. hazard zone, underground services etc.)

(A) safety control to reduce or eliminate hazards

(B) sequence of basic job steps in order

(B) potential hazards. (e.g. hazard zone, underground services etc.)

(B) safety controls to reduce or eliminate hazard

(C) sequence of basic job steps in order

(C) potential hazards (e.g. underground services, hazard zone etc.)

(C) safety controls to reduce or eliminate a hazard

(D) sequence of basic job steps in order

(D) potential hazards (e.g. underground services, hazard zone etc.)

(D) safety controls to reduce or eliminate hazard

(E) sequence of basic job steps in order

(E) potential hazards (e.g. underground services, hazard zone etc.)

(E) safety controls to reduce or eliminate a hazard

Equipment ( list of equipment and its storage on site, only if relevant to safety)

List

Yes No N/A

additional PPE ( minimum requirement: gloves, glasses, hard hat, safety boots, visi-vest)

Hearing protection

Yes No N/A

Fall protection

Yes No N/A

Eye protection

Yes No N/A

Portable gas monitor

Yes No N/A

Rubber footwear and gloves if in a damp area

Yes No N/A

Other (fire retardant coveralls, breathing apparatus, etc) specify :

relevant outside authorities:

(check name not set)

outside authorities (signature)

disposal of designated substances, surplus, or impacted materials (including details)

(check name not set)

signature

retailer or sales associate

prepared by (please sign)

date

Select date

person carrying out the work (please sign)

date

Select date

person carrying out work (please sign)

date

Select date

person carrying out work (please sign)

date

Select date

site supervisor

JSA approved retailer or sales associate (please sign)

date

Select date

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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.