Job Safety Analysis Form (JSA)
Pre-Task Assessment to be completed before work activities begin.
API Inc. Department
*
Please Select
Nyco
API Garage Door
APICC - Minnesota
APICC - North Dakota
APICC - Upper Michigan
APICC - Lower Michigan
M Lukas
Milwaukee Scaffold
National Scaffold
Portland Scaffold
Scaffold Service
Project Name
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Work Task / Work Area
*
Supervisor
*
Date
*
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Month
-
Day
Year
Date
Hour Minutes
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example@example.com
Do you believe this is High Risk work?
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Yes (If Yes contact you supervisor to get issues resolved.)
No
If Yes, what makes this high risk work?
If Yes, what was done to fix the issues?
Is Stop Work Authority understood?
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Yes
No
Were daily stretching exercises completed?
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Yes
No
Confined Space Permit required?
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Yes
Not Applicable
Confined Space Operations
Permit completed and signed.
Air monitor in use.
Air monitor bump tested.
Air monitor calibrated.
Entry team is trained.
Emergency Rescue Team available.
Hot Work Permit required?
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Yes
Not Applicable
Hot Work Operations
Permit Signed
Combustibles Removed
Fire Blanket in use
Fire Extinguisher present
Fire Watch
Spark Containment
Monitoring for flammable atmosphere
Lockout / tagout required?
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Yes
Not Applicable
Lockout / Tagout Operations
Employees trained in LOTO.
LOTO process reviewed and followed.
Each employee assigned a unique lock and key.
Personal Fall Arrest System required?
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Yes
Not Applicable
Personal Fall Arrest System Operations
Harness Inspected
Self Retracting Lanyard Inspected
Anchor point able to hold 5000 lbs.
Emergency Rescue Plan discussed.
Fall Hazard Identified
Work Area Conditions (Select all that apply)
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Heat or Cold Stress
Standing Water
Poor Air Quality
Electric Shock
Inadequate Lighting
High Noise
Poor Housekeeping
Trip Hazards
Slip Hazards (Mud, Ice, Snow, Oil)
Sharp Objects
Tight Work Area
Low Headroom
Operating Equipment
Chemical Hazards
Flammable Hazards
Pinch Points
Overhead Crane Lifts
Other
PPE: 100% Use of Standard PPE of Hard Hat, Foam Lined Safety Glasses, Cut Level 4 Gloves required. Select additional PPE below:
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Goggles
Face Shield
Tyvek Suit
Impact Gloves
Dust Mask
Hearing Protection
Other Respirator Protection
No Additional PPE Required
Other
Dropped Object Prevention
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Tool Lanyards on all tools.
Caution Barricade Tape and Signs
Danger Barricade Tape and Signs
No Dropped Object Prevention Required
Safe Access to the Work Area:
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No Special Access Required
Scaffold Inspected
Ladder Inspected and Secured
Scissorlift Inspected
Aerial Lift Inspected
Aerial Lift Map Completed
Spotter
Tools Inspected Before Work Starts:
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Grinder guard and handle in place.
Electrical tools and cords inspected.
Extension cords hung up.
GFCI Tested
Not Applicable
Special Hazards to Consider for Removal Work:
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Verify insulation is non-ACM or non-PACM
Employ a dust control measure.
Punctures and cuts can become infected.
Maintain good housekeeping and debris control.
Not Applicable
Crane Lifts
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Not Applicable
Rigging Inspected
Signal Man Trained
Rigger Trained
Vacuum Lifting Attachment Charged and Inspected
Other Crafts in the area?
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Yes
No
What other crafts are in the area?
What hazards are they creating?
What corrective actions are in place?
Are they aware of our hazards?
Yes
No
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Work Step #1
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Work Hazards Associated with Work Step #1
*
Corrective Actions for Step #1 Work Hazards
*
Work Step #2
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Work Hazards Associated with Work Step #2
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Corrective Actions for Step #2 Work Hazards
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Work Step #3
Work Hazards Associated with Work Step #3
Corrective Actions for Step #3 Work Hazards
Work Step #4
Work Hazards Associated with Work Step #4
Corrective Actions for Step #4 Work Hazards
Work Step #5
Work Hazards Associated with Work Step #5
Corrective Actions for Step #5 Work Hazards
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All employees reported to work injury free?
Yes
No (If no, contact your Supervisor.)
Employee 1 Print In:
*
First Name
Last Name
Employee 1 Sign In:
*
Employee 1: Were you injured today?
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Yes (If yes, notify your Supervisor immediately.)
No
Employee 2 Print In:
First Name
Last Name
Employee 2 Sign In:
Employee 2: Were you injured today?
Yes (If yes, notify your Supervisor immediately.)
No
Employee 3 Print In:
First Name
Last Name
Employee 3 Sign In:
Employee 3: Were you injured today?
Yes (If yes, notify your Supervisor immediately.)
No
Employee 4 Print In:
First Name
Last Name
Employee 4 Sign In:
Employee 4: Were you injured today?
Yes (If yes, notify your Supervisor immediately.)
No
Employee 5 Print In:
First Name
Last Name
Employee 5 Sign In:
Employee 5: Were you injured today?
Yes (If yes, notify your Supervisor immediately.)
No
Employee 6 Print In:
First Name
Last Name
Employee 6 Sign In:
Employee 7 Print In:
First Name
Last Name
Employee 7 Sign In:
Employee 8 Print In:
First Name
Last Name
Employee 8 Sign In:
Employee 9 Print In:
First Name
Last Name
Employee 9 Sign In:
Employee 10 Print In:
First Name
Last Name
Employee 10 Sign In:
Employee 6: Were you injured today?
Yes (If yes, notify your Supervisor immediately.)
No
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