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Job Safety Assessment (JSA)
Date
-
Month
-
Day
Year
Date
Your Name
First Name
Last Name
Your Email
example@example.com
Project Name
Is this a printed JSA?
Yes
Upload Photo or PDF of your completed JSA
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Muster Area
Todays Tasks
Tools & Equipment Required
Permits Required
None
Hot Work
Excavation
Lock Out/Tag Out
Confined Space
Job to be Performed
Job Tasks
Job Hazards & Controls
Check all items that apply to the intended work and give details as needed in the Tasks, Hazards, and Controls section of this form.
Safety Orientation
All employees have completed the Company Safety Orientation Awareness Training located at www.bms.support
Stop Work
Every worker understands the obligation to stop unsafe behaviors or conditions
You see it, you own it
Driving
Seat belts used at all times
Drive on authorized routes
Condition of road or route
Spotter/ safety watch required
Unattended operation
Vehicle inspection
All loads secured
Other
Electrical Safety
Grounding and bonding
GFCI for electric power tools
Safe distance from energized lines and equipment
Power cords inspected
Power tools inspected
Water not puddled at electric equipment
Other
Emergencies & Communication
Communication resources available to call for help if needed
Emergency Action Plan has been completed at www.bms.support
Radios charged and in working order
Alarms working
Horns working
Other
Environmental Issues
Bees, wasps, hornets, yellow jackets
Insects
Bears
Mountain Lions
Snakes
Wildlife
Other
Excavations & Trenching
Utility locate performed
Lines located, marked and drawings reviewed
Confined space concerns
Approved shoring in use
Proper sloping
Proper barricading around open holes
Proper egress provided
Competent person present
Permit requirements met
Other
Hazard Communication
Chemicals
Toxins
Flammables
Spill Prevention & Response
Safety Data Sheets & Right to Know Center
Other
Heavy Equipment Concerns
Current operator certification on file
Equipment daily inspections completed
Equipment swing radius clear
Positioning and outrigger location addressed
Overhead or underground power lines, utilities, etc.
Air horn or other communication
Signal man or spotter
Pinch points or caught betweens
Soft, hard, muddy, wet, sloped ground
Area cordoned off, barriers, flagging, caution and hazard tape
Other
Hot Work
Fire extinguishers at job location
Fire watch identified
Flammables, combustibles or LEL concerns controlled
Fire blanket necissary
Ground lead as close to welding operations as possible
Proper work attire
Proper eye protection
Other
Housekeeping Discussion
Job location clean and free of hazards
No clutter present in walking and work areas
Garbage in the appropriate containers
Signage present as necessary
Are tools and equipment clean and orderly
Other
Lock Out/ Tag Out
LOTO Training current
Walk through and discussion of LOTO
Energy source is isolated and locked out
Breaker open and locked
Mechanical energy released
Isolation method tested
Assured grounding
Risk of trapped or non-isolated energy
Other
Personal Protective Equipment (PPE) Adequate
Hardhat, safety glasses, safety-toed boots
Face shield, goggles or spoggels
Hearing protection
Gloves
Respiratory protection
Eyewash station- location identified
Proper attire for the job (welding, snakes, etc)
Other
Personnel Concerns
New employees/ inexperienced workers
Workers fit for duty (medications, sleep, physical limitations, distractions, etc.)
Workers clean and sharp with buttoned and zipped outer attire
Language barriers addressed
Other
Task Hazards Discussion
Ergonomic concerns (bending, lifting, etc.) Potential for slips, trips and falls
Caught between hazards
Hand tool inspection
Fire hazards
Others working overhead or below
Other jobs in area (SIMOPS)
Other
Work Area Hazards Conversation
Confined space concerns
Moving equipment or vehicles
Lighting levels too high/ low
Extreme heat or cold
Severe weather
Excessive winds (high profile structures, flying dust & debris)
Uneven, wet, slippery, or muddy ground (unstable footing)
Ignition sources, static, grounding (Hotwork)
Overhead utilities
Underground utilities
Other
Working at Heights
Man lift inspected
Fall protection requirements understood
Proper tie-off points identified
Full body harness and lanyard/ lifeline
Fall protection equipment inspected
Ladder safety addressed
Walking and working surfaces restricted, narrow, wet, slippery or icy
Scaffolding in proper order
Area cordoned off below work
Other
Additional Hazards
Additional Controls
Workers/Persons Present (initials)
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