Job Safety Analysis

Job Safety Analysis (JSA)

Complete BEFORE starting work
USA 811 Ticket Number*
Use N/A if aerial without anchors
Ticket Expiration Date*
Use N/A if aerial without anchors
Date*

MonthDayYear
Date
Office*

Phoenix, AZRochester, NYGainesville, FLFlorence, SCLawton, OKNevadaColoradoMichiganLima/Findlay OHIndianapolis, INKentuckyOther
Your Name*

First NameLast Name
Manager's Email*
example@example.com
Jobsite*
Task Overview*
Business Partner Company Name
Put ByVerTek for In-House
TYPE OF WORK*

Aerial - Install StrandAerial - Replace Spans of Coax HardlineAerial - Sweep & BalanceAerial - Splice CoaxAerial - Place Fiber and LashAerial - Guys and AnchorsAerial - Splice FiberAerial - Pole Transfer/RemovalUG - LocatingUG - DrillingUG - TrenchingUG - DiggingUG - Property RestoralUG - Pulling ConduitUG - Pulling FiberUG - Splicing FiberTraffic Control - Set ConesTraffic Control - Set SignageTraffic Control - Flag TrafficOther
BREAK SCHEDULE REVIEWED WITH CREW

YesNo
IDENTIFIED HAZARDS

Air Born ParticulatesBarricades NeededBelow Ground HazardsElectrical ShockFall HazardsFire HazardsGround Fall ProtectionHand Tools (Right Tool For The Job)Heat Stress (Drinking water on site)Heavy Objects (lifting)High Noise LevelsHousekeeping Done Daily?Hot/Cold SurfacesLadders (inspected, position right, etc...)Material Storage and HandlingMSDS (chemical hazards)Overhead HazardsPower Tools (inspected & guarded)Restricted Access / EgressRight Tool For Right JobRestricted LightingSharp Objects / Pinch PointsSlip & Trip PotentialsExposure to Heat or ColdHeat Exhaustion/Heat StrokeFrostbite/HypothermiaAnimalsInsectsOther
PPE (Check all that Apply)

Safety Glasses (Required at all times)Safety VestHard Hat (Required at all times)Face Shield (Required Operating All Power Tools)Goggles (Chemical Hazards)GlovesHearing ProtectionFall Protection PlanSteel-toe Foot Protection (No Athletic Shoes)RespiratorAir Monitor (Vaults & Manhole)Other
HEAVY EQUIPMENT NEEDED (Check all that apply)

Backhoe/Mini-excavatorBobcatCompactorCraneDozerForkliftAerial Lifts (All Types)TrencherAir CompressorMissileDrillAugerOther
EMPLOYEE AFFECTING HAZARDS

Struck AgainstCaught InFall Same LevelStruck ByCaught OnFall To BelowContact WithCaught BetweenOver ExertionContact ByExposureHeat StressConfined SpaceOther
SAFETY HAZARD STATUS

SITE OK READY TO GO

The site has been surveyed and there are no identified hazards

HAZARDS ADDRESSED

The hazard(s) are been addressed and the workers are aware of the hazards and steps have been taken to eliminanate or avoid them.

STOPPED WORK

The hazards cannot be resolved in time for the work to commence or be completed.

RESOLVED

The hazards that caused the STOPPED WORK status are resolved and the site is now ready for work.

COMMENTS

In the Status Comments section, describe:
- Identified hazards in detail,
- Who is affecetd or at risk
- Any danger to property
- If any public safety agencies (Police or Fire) were called to the location
PHOTOS & VIDEOS

When taking photos we suggest a camera app that overlays GPS data and date and time. Keep videos very short.
STATUS (Inc. Photos)*

SITE OK READY TO GOHAZARDS ADDRESSEDSTOPPED WORKRESOLVEDOther
Upload Photos or Videos*

Add photos and videos of the hazard plus video of team acknowledging that you explained this to them.
Cancelof
Status Comments*
INDICATE DATE AND TIME WORK STOPPED.
Your Full Name*
Acknowledgement
Your Signature*

Clear
Names of Employees This Information Was Explained To (Name 1, Name 2, Name 3, etc...)*
IMPORTANT!

Any critical safety issue, contact your manager.
Should be Empty:

Job Safety Analysis (JSA)

Acknowledgement