T&M JSA
Each job is requires a completed Job Safety Analysis. All employees and subcontractors must complete a Job Safety Analysis with all crew members and visitors who enter the work area.
Name
*
First Name
Last Name
Your Email
Date
-
Day
-
Month
Year
Date
Task(s)/Job(s) Being Preformed
Project/Location Name/Number
Company you work for
*
Division you work for. (Choose all that apply)
Williston
Bismark
South Texas
West Texas
New Mexico
Washington
Idaho
Oregon
Construction
Trucking
Shop
Office
Other
Foreman
First Name
Last Name
Foreman Email
example@example.com
Client Company Name
Client PIC
First Name
Last Name
Email
example@example.com
Writen JSA from front, or of the job site
Take Photo/Upload Files
Cancel
of
Writen JSA from Back, or of the job site
Take Photo/Upload Files
Cancel
of
Writen JSA from front, or of the job site
Writen JSA from Back, or of the job site
Detected Location
Photo from file
Photo from file
Draw Map of Hazards/Emergency Locations: Muster area, exits, overhead power lines, buried hazards etc...
Permit(s) Required
None
Excavation
Fluid Transfer
Lock Out / Tag /Out
Critical Lift
Confined Space
Hot Work
ROW Clearance
Safe Work
Work @ Height
Job Hazards & Controls
Check all that apply and give details as neededin the TASK, HAZARDS & CONTROLS Section of this form
The Following Hazards and Controls were Identified and Discussed
STOP WORK
Stopping unsafe acts and/or conditions is not your right, it is your obligation and a condition of employment
Other
WORK AREA HAZARDS
Equipment/vehicles
Severe weather
Extreme heat/cold
Excessive wind, flying dust/dedris
Unstable footing, uneven, slippery muddy
Overhead utilities, restricted clearance
Confined Space
Working near/under energized lines
Site clearance restrictions (access perm
Other
TASK HAZARDS
Ergonomic bending, lifting, etc
Slip/Trip & Fall potencial
Caught between hazards
Hand tool inspection
Fire hazards
Others working overhead/below
Exposure to vibration
Repetitive or sustained force
Repetitive movement
Other
EMERGENCY & COMMUNICATION
RIchard Bunker 435-253-0716
Emer. comm. avalible to call responders
Emergency Action Plan present
Other
HOUSEKEEPING
Work area clean /free of hazards
Clutter on site/work area
Garbage/debris on ground
Tools/equipment clean/orderly
Other
PERSONNEL CONCERNS
Clean/sharp button/zipped outer attire
New employees/inexperienced SSE's
Fit for duty (Meds, sleep, phys limit
Language barriers addressed
Other
ELECTRICAL SAFETY
Grounding and bonding
GFCI for electric power tools
Safe from energized lines/equipment
Clearance requirements
Other
PERSONAL PROTECTIVE EQUIPMENT (PPE)
Hardhat, safety glasses, Steel-toe
High visibility clothing/ vest
Face shield, goggles or spoggels
Gloves
Hearing protection
Respiratory protection
Attire for job (welding,snakes,etc)
FRC-flame-resistant clothing
Other
HOT WORK
Fire extinguisher/equip avalible
Fire watch
Flammables/Combustibles or LEL
Fire blanket
Ground rod bucket
Ground lead as close as possible
Proper work attire
Proper PPE
Other
DRIVING MOTORIZED EQUIPMENT
Seat belts used at all times
Operator is qualified
Driver logs maintained
Vehicle/equipment inspection
Maintained lights, horns, tires etc.
Condition of road or route
Spotter when required
Unattended operation
Windows clean/unobstructed
No loose tools/debris in cab
All loads secure
Defects do not affect safe operation
Other
HEAVY EQUIPMENTOR/CRANES
Permit required
Operator is qualified
Current operator certification on file
Equipment daily inspections completed
Equipment swing radius clear
Positioning/outrigger location addressed
Overhead power lines, utilities, etc.
Air horn or other communication
Spotter or signal man
Soft, hard, muddy, wet, sloped ground
Rigging/attacments inspected
Area cordoned off
Other
EXCAVATIONS AND TRENCHING
Utility locate performed
Lines located/marked & drawings rvwd
Confined space concerns
Approved shoring in use
Proper sloping
Proper clearance of spoils/equipment
Proper barricading around open holes
Proper egress provided
Competent person review
Water in exavations
Permit requirements
Other
EXCAVATIONS AND TRENCHING
Utility locate performed
Lines located/marked & drawings rvwd
Confined space concerns
Approved shoring in use
Proper sloping
Proper clearance of spoils/equipment
Proper barricading around open holes
Proper egress provided
Competent person review
Water in exavations
Permit requirements
Other
ENERGY ISOLATION
LOTO Training varified
Inspection,/walk/discussion of LO/TO
Isolated and locked out & tried out
Stored energy released
Breaker open and locked
Assured grounding
Risk of trapped or non-isolated energy
Other
ENVIRONMENTAL ISSUES
Spill mitigation or containment
Spill contaiment kit avalible
All connections inspected
Right To Know Center location known
SDS reviewed
Means to protect ground @ connections
Equipment inspected prior to transfer
Other
ADDITIONAL HAZARDS "SAVE" after each additional hazard
ADDITIONAL CONTROLS "SAVE" after each additional control
PERSONNEL PARTICIPATING IN JSA “SAVE” after each person is added
SIGNATURE(S) of personnel participating in the JSA and performing the work
Submit
Clear Form
Print Form
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