JOB SAFETY ANALYSIS (JSA)
Date Issued:
Project Manager:
Company:
Lease Name:
Legals:
Job Specification:
MINIMUM REQUIRED PERSONAL PROTECTIVE EQUIPMENT (see job steps for task-specfic requirements)
q
q
q
q
q
q
q
q
Reflective Vest
Hard Hat
Lifeline/Harness
Safety Glasses
First Aid Kit
Rubber Boots & Apron
Rescue Laynard/Rope
Lights
q
q
q
q
q
q
q
q
Goggles
Face Shield
Hearing Protection
Safety-toed Boots
H2S or 4-Gas Monitor
Ground Static Cable
Wheel Chocks
Other
q
q
q
q
q
q
q
Supplied Air
q SCBA
q Airline Respirator (attach description)
q Other
APR
q Full APR
q Particulate
q Half APR
q Particulate/Org Vapor Combo
q Other*
q Acid Gas
Gloves
FR Ins.Coveralls
PPE/FR Clothing
Fire Extinguisher
Helmets (ATV)
Lockout/Tagout
Communications
ADDITIONAL PPE (*provide specific type(s) or description of this item below)
Pre-Job Assessment
Lifting
Manual Lifting
Mechanical Lifting Equipment
Awkward Body Position
Slip/Trip Potential
Lifting w/other Employees
Proper Rigging
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N/A
N/A
N/A
N/A
N/A
N/A
Access/Exit
Handrails
Ladders/Stair Rails Placement
Barricades Placed
Secure Footing
Evacuation Routes Identified
Y
Y
Y
Y
Y
N
N
N
N
N
N/A
N/A
N/A
N/A
N/A
Confined Space Permit
Does Work Involve Confined Space? Y N N/A
If yes, follow Confined Space Policy
Work Plan
Has a Work Plan been developed?
If yes, attach JSA to work plan
Y N N/A
Hazards
Proper Tool/Material Placement
Hot/Cold Surface or Material
Inadequate Lighting
Fall Protection/Anchor Points
Pinch Points
Hand & Finger Hazards
Electrical Hazards
Welding/Flame Cutting
Mechanical Equipment
Road Gear & Derrick Locked & Tagged
Are all containers properly labeled?
Is H2S Present?
Insects/Snakes
Water Hazard
Non-English Speaking Employees
Asbestos Awareness
Benzene Awareness
Cell Phone Usage
Driving Safety
Fire Protection
General Waste Management
Simultaneous Operations
Are simultaneous operations, occuring on site?
Have all operations been notified of work being performed?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y N N/A
Y N N/A
Excavation/Trenching/Drilling
Does work involve excavation, trenching, drilling, etc.
Y N N/A
Has One Call Notification been made?
Y N N/A
One Call Notification #
One Call Notification Date
*Must wait 48 Hours after notification before excavation, trenching, and drilling
Hazards Continued
Incident Investigation & Reporting
Injury/Illness Recordkeeping
Lead & Lead Awareness
Natural Occurring Radioactive Material (NORM)
Noise Awareness
Noise Exposure/Hearing Conservation
Subcontractor Management Plan
Vacuum Truck Usage
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Body Position/Movement
Climbing
Pulling, Pushing
Bending
Twisting Motion
Walking
Crawling
Straining
Stretching
Reaching
Over Extending
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Lockout/Tagout
Does work require lockout/tagout?
Person Responsible for LOTO
Y N N/A
Hot Work Permit
Is a Hot Work Permit Required?
If yes, follow Hot Work Policy
Y N N/A
Field staff must review job-specific work plan and coordinate with project manager to verify that all up-front logistics are completed prior to starting work including,
but not limited to, permitting, access agreements, underground utililties and notification to required contacts (e.g., site managers, inspectors, clients, subcontractors,
etc.). Additionally, a tailgate safety meeting must be performed and documented at the beginning of each workday.All personnel must posses the appropriate
training prior to initiating scheduled tasks. Also consider weather conditions. ECS personnel have authority and responsibility to use Stop Work Authority.
Sequence of Basic Job Steps
Potential Hazards
Corrective Measure(s)
Job Safety Observations
Environmental Conditions
Wind Speed & Direction:
Supervision
Availability
Location
Type of Job
Work Area
q None
q Intermittent
q Foreman
q On Location
q Elevated
q Below Ground Level
q Confined Space
q Ground Level
q Routine
q Medium
q Complex
q Open
q Tight
q Congested
Hospital Name
Weather:
Temperature:
Hospital Phone #
Light Conditions:
Communication
During the Task
Emergency Phone #
q Written
q Verbal
q Hand Signal
q Intrinsically Safe Radio
Driving Directions
Crew Members, Company Representatives & Third Party Signatures
Name
Signature
Name
Signature