PRE-JOB SAFETY ASSESSMENT - PSA FORM
Review the following at the work site and ONLY check the items which apply to the task. List all the task and hazards you have checked on the TASK/HAZARD/CONTRL table. In the CONTROL column detail your control method(s). Identified "HIGH RISK" task require Job Hazard Analysis c/w step-by step procedure.
Date
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Month
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Day
Year
Date
Company:
Project:
Trade:
Project #:
Supervisor:
Specific Task Location:
Access/Work Location Hazards
Partially obstructed
Slip/Trip potential
Below Grade
Above Grade
Scaffolds / elevated work platforms
Ladders
Near edges/floor opening/shafts
In shaft/ other trades in work location
near vehicle/equipment traffic
Active Hoist/Swing area
Working in excavation/shoring
Other persons above or below the work area
Energized equipment in area
Sensitive equipment in are
Other
Work Environment Hazards
Spill potential
Weather Conditions
Inadequate Ventilation
Heat Stress / Cold exposure
Other workers in area
Inadequate lighting
Housekeeping
Loose materials
Other
Work Environment Hazards
Dust
Silica/Concrete
Chemical
Mould
Other
Activity / Equipment / Tool Hazards
Burn/Heat sources
Compressed gases used
Welding/Grinding
Electrical cords/tools
Equipment/tools
Stored energy/potential energy
Airborne particles/chipping/grinding
Activity creates vibration/noise/light hazard
Tools/Equipment not serviceable
Tools/Equipment not appropriate
Tools/Equipment misused
Other
Personal Limitations / Hazards
Inadequate Planning/Communication
Inadequate training and/or experience
Distraction in work area
Working alone (communication)
Lift too heavy/awkward position
External noise levels
Physical limitations/conditioning/health
Violence/Harassment
Other
Controls: Shutdowns/Permits - signed/posted
Rail Briefing
HVAC Shutdown
Fire/Smoke Bypass
Electrical
Water
Confined Space Permit
Hot Work Permit
Locates/Excavation Permit
Pre-work Stretch and Flex Program
Other
Ergonomic Hazards
Working in tight area
Parts of body in line-of-fire
Working over your head
Pinch points/nip points
Repetitive motion
Repetitive work in awkward position
Overexertion
Other
PPR Requirements
Mandatory: CSA Approved hard hat
Minimum 6" CSA green patch boots
Safety glasses / full face shield
Hi-Vis(High Visibility) Upper Garment
Respiratory Protection
Hearing Protection
Personal Fall Protection
Other
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Tasks
Task, Hazards, Controls
Task:
Hazards:
Controls:
Task:
Hazards:
Controls:
Tasks:
Hazards:
Controls:
Task:
Hazards:
Controls:
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Attendees
Name
*
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AM/PM Option
Are you Fit For work?
*
Yes
No
Do you need gloves?
Yes
No
Do you need safety glasses?
Yes
No
Have you stretched and flexed?
Yes
No
Did you experience an injury today?
Yes
No
Worker Finished:
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AM/PM Option
Name
*
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AM/PM Option
Are you Fit For work?
*
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Do you need gloves?
Yes
No
Do you need safety glasses?
Yes
No
Have you stretched and flexed?
Yes
No
Did you experience an injury today?
Yes
No
Worker Finished:
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AM/PM Option
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Next
Deaily Report: # Supervisors:
*
#Workers
Type a question
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AM/PM Option
Major Equipment:
Work Areas:
Comments/Remarks
(Include Safety Activities eg. toolbox talks, incidents, etc.)
Supervisor:
Submit
Should be Empty: