AP4 Services: Job Safety Analysis v2

Job Safety Analysis

AP4 Services JSA
AP4 EMERGENCY CONTACTS

ONLY AFTER EMERGENCY CARE HAS BEEN PROVIDED
PLEASE, CALL AND TALK TO AT LEAST ONE OF:

Service Manager: Sophia Hostetler Cell # 423-766-0473

Service Manager: Esteban Barrientes Cell# 832-725-2668
Service Director: Alex Gerela Cell# 970-946-0641

DO NOT SEND TEXT OR LEAVE VOICE MAIL.
Client Information

Pre-Populated From Connected Service Manager From
Customer Company Name:
Customer Contact Person:

First NameLast Name
Customer Contact Email:
example@example.com
Customer Contact Phone Number:
Please enter a valid phone number.
Customer / Work Location Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
JSA Date of Completion:

MonthDayYear
Date
Job Number:
JSA Completed By:

First NameLast Name
JSA Completed By (This will Send You a Copy)*
example@example.com
Job Start Date

YearMonthDay
Date
Job End Date

YearMonthDay
Date
Job Activity Name
JSA REV #
EHS Notes

Exciter testing with control power applied:
EHS Test before touch, slips trips and falls. Wear proper PPE, Heat stress due to high outside temperature
NOTES Exciter testing with 4160VAC power applied:
Test before touch, observe arc flash boundaries, wear proper PPE
Safety GlassesChemical GogglesFace ShieldWelding GogglesSafety Toed ShoesHard HatHarness and LanyardHearing ProtectionStandard GlovesElectrical Rated GlovesFR ClothingOther
If "Other" Explain
(e.g. Cut Resistant Gloves, 4X Gas Monitors, etc.)
Site Induction Date

MonthDayYear
Date
Safety Protocol Review Date

MonthDayYear
Date
LOTO Preliminary Procedure Date

MonthDayYear
Date
Applicable Confined Space Review

MonthDayYear
Date

Please list the steps required to complete the task, the associated hazards, and what mitigation steps you intent to take to manage the risk.

Rows	Description of Task	Applicable (Y/N)	Potential Hazard / Accidents	Recommended Safe Job Procedure
Job Step 1
Job Step 2
Job Step 3
Job Step 4

Upload a File (If Needed)

Cancelof
Site Lead Name:

First NameLast Name
Team Member 2 Name:

First NameLast Name
Team Member 3 Name:

First NameLast Name
Team Member 4 Name:

First NameLast Name
Should be Empty:

Job Safety Analysis

Client Information