JOB SAFETY ANALYSIS Contractor's Name Foreman's Name Date Permit Required: Location Equipment # Job # Permit# Permit Expiration Time of JSA: Opening/Building Cold/General Work Hot Work Entry Other (Explain) Maintenance Procedure Required: If “Yes”, list the name of procedure YesNo TO REPORT A FIRE OR MEDICAL EMERGENCY DIAL Wind Direction: Safety Shower/Eyewash Location: Tested First Aid is location at the Seal: YesNo Inspection Date: Fire Extinguisher Location: Primary Evacuation Location: Secondary Evacuation Location: Contractor Off-site: Personal Protective Equipment (PPE) Assessment: Hard Hat YesNo Safety Footwear YesNo Molded Side Shields YesNo FRC YesNo Safety Glasses w/ YesNo Goggles Chemical YesNo Hearing Protection YesNo Double Protection YesNo Proper Type of Gloves YesNo Fall Protection YesNo Rainsuits YesNo Face Shields YesNo Breathing Air YesNo Full - Face Mask YesNo Half - Face YesNo Others YesNo Cartridge Type Chemical Resistant Clothing Type: Personal Monitors Type: All tools/equipment brought on site are in safe operating condition, and inspection is current: Yes Informed mechanical contact of any unique hazards related to the contracted service and receivedauthorization to proceed prior to the start of work: Yes I have read and understand the job scope and PERMIT and agree to adhere to all safety precautions and procedures to complete this job safely: (All employees sign before starting work) Access (Fall protection, Confined Space, Muddy, Congested, Uneven Ground, Overhead Obstructions) Chemicals/Materials (In immediate area or brought on-site for PAAI and MSDS available) Environment (Noise, dust, weathering, lighting, heat, hazardous atmosphere, etc.) Physical (Body positioning, sharp objects, pinch points, hot/cold surfaces, open holes, overhead workers, etc.) Potential Energy (Lock Out/Tag Out in place, GFCI tested, power lines, static electricity, etc.) Tool/Equipment (Hazards of tools, heavy machinery, weld arcs, rigging, etc.) Scaffolding (Scaffold tagged, user inspection, fall protection, etc.) Other (List others identified) Field Representative’s Name: End of Day Checklist: Area cleaned up? YesNo Barricades removed? YesNo Process updated ? YesNo Sewer removed? YesNo Permits signed off? YesNo personnel accounted? YesNo Accessroutes/fireclear? YesNo Permits turned in? YesNo JSA turned in? YesNo JSA turned in? Yes End of Day Checklist completed by: Hazards identified requiring follow-up: THIS DOCUMENT IS TO BE TURNED IN TO THE SAFETY DEPARTMENT AT THE END OF EACH JOB.
