JSA
Weekly or daily job site hazard analysis form. As duties and workers change so shall this form.
Date
*
-
Month
-
Day
Year
Date
Work area location?
*
Job site address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency contact?
On-site emergency - Hospital location or 911
Who is onsite?
First names are fine
Inspection checklist. Check all of these items daily before use.
Anchors
PPE
Ropes
The structure
Housekeeping
Ronin Climbers
Lifts -Swing Stages
Electrical hazards
Equipment
Other
If anything does not pass inspection please set the item aside and mark it non-compliant as soon as possible.
*
Check if agree.
What are the tasks of the day or week?
Climbing
Pressure wash
Scraping rust or old paint
Mixing paint
Rigging
Cutting
Power tools
Access methods
Lifting
Spray painting
Driving
Other
What hazards do our tasks present?
Falls
Trauma
Slips and trips
Hitting head
Cutting skin
Debris in eyes
Heat or cold stress
Dehydration
Pulled muscles
Burns
Injection into skin
Pressurized line problems
Other
How can we control these hazards?
*
Use proper lifting techniques
Cut away from body
Electrical is grounded
Wear eye protection
Wear a helmet
Keep items off floor
Be cautious
Drink liquids get out of the heat
Wear proper clothing
100% tie-off at all times
Good housekeeping
Make sure all pressurized lines are secure
Two rope system
Follow road rules
Ensure all guards are in place and operational
Other
Rigging plan for fall protection and rope access
Each rope/person on a separate anchor
Each anchor to withstand marked 2500lbs or 5000lbs unmarked
100% tie off
Two independent line systems for RA
Horizontal lifelines to maintain safety factor of at least two (OSHA 1926.502(d)(8))
Other
Rescue plan - Site lead or designated person will delegate tasks to non injured persons. Please secure the injured ASAP, within 20 minutes. The use of 4:1 or Milan to lower person to safe space. Keep either item in designated place close to work area. Site lead calls 911 or instructs someone to call 911
Type Ok or any deviations
First aid kit and rescue kit location area:
*
Emergency / evacuation meeting area:
Evacuation Plan - 1. Emergency declared 2. Airwaves cleared 3. All personnel rendezvous to rescue gear location 4. Asses area and situation 5. Take roll call 6. Immediately move to designated meeting area outside of work area 7. Call 911
Type Ok or any deviations
Other information:
Signature
*
Signature
Signature
Signature
Signature
Signature
Print
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Submit JSA
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