Jsa checklist
Job safety analysis
What does this form include?
This form contains 18 sections:
Work \ Job \ Task Specific Location:
Prepared By:
Approved by:
JSA REQUIREMENTS 1 The JSA must be reviewed/revised daily, after a stoppage in work, or if work condi
Permit(s) Required
- HOT WORK
- CONFINED SPACE
- ENERGY ISOLATION - LOTO
- OTHER: (ie, cold work, open water, non flame, etc.)
List permit required
HAVE YOU?
- Visited the work site?
- Completed Pre-Job Planning/Potential Hazard Checklist and ensured appropriate hazard control methods implemented?
- Is a written released procedure available? Has procedure gone through the LST review process? (If no, additional SME involvement and sign-off required). Procedure attached to JSA form? Procedure #
- Has everyone involved in the work particiapated in the JSA process?
- Has all personnel been assigned specific responsibilities and those responsibilities communicated/understood by all team members?
- Involved a Technical Expert or other SME (Subject Matter Experts) as applicable?
JOB DESCRIPTION (general)
Personal Protective Equipment (check all that is appropriate)
- Safety Glasses
- Goggles
- Face Shield
- Hard Hat
- Gloves
Type of gloves
List other:
Special Equipment and/or Other Safety Precautions (Check all that apply)
- HPU/ High Pressure Hoses
- Whip Checks
- Red Flashing Lights
- Blast Shields with sand bags
- Cameras/ Mirrors
- Crane & Tag Lines
- Spotter/Signaler
- Rigging
- Barrier Tape
- Heating and Cooling
- Manlift
- Forklift
- Fall Arrest System
- Paltform ladder/Ladder
- Lighting
- Work Tables
- Torque Tables
- Hi-Torque
- Pressure Washier
- Spill Response Cart
- Emergency Retrieval/Rescue Plan
- Emergency Response Plan
- Fire Extinguisher
- Fire Watch
- Other:
For each identified hazard, you should always attempt to address/control using the below methods in t
Job Sequence - Task Breakdown (be specific & detailed)
Identified Hazard(s)/Risks
Hazard/Accident Controls
Responsible Person(s) (be specific)
Technician Name:
Use this template