Job Safety Assessment (JSA)
Job & Site Information
Date
*
-
Month
-
Day
Year
Date
Completed by
*
Daniel Wiener
Andrew Haggarty
Adam Keene
Sophia Nickerson
Allen Taylor
Other
Employee Name If Other
Client name
*
Address Search & Preview
*
Nearest hospital
*
Central/South/SW Seattle: Harborview Cap Hill: 325 9th Ave, Seattle, WA 98104
Burien/NP/SSW Seattle St Anne ER: 16251 Sylvester Rd SW, Burien, WA 98166
Northwest Seattle: UW NW Campus ER, 1550 N 115th St Fl 1, Seattle, WA 98133
Northeast Seattle: UW Medical Ctr, UW Campus: 1959 NE Pacific St Fl 2, Seattle, WA 98195
Ballard/Magnolia Seattle: Swedish ER, 5350 Tallman Ave NW, Seattle, WA 98107
Bellevue: Overlake Medical ER, 1035 116th Ave NE, Bellevue, WA 98004
Renton: Valley Medical ER, 400 S 43rd St 1st Floor, Renton, WA 98055
Other
Emergency equipment
*
Phone
First aid kit
Fire extinguisher
Other
Emergency plan: Call 911 for all life threatening emergencies
Describe the overall scope of work for this job:
*
Pruning
Removal
Cabling/bracing
Planting
Stump Grinding
Other
Describe Other
Will any of the following special operations be performed?
Woodchipper operations
Climbing operations
Rigging
Excavation / stump removal
Chainsaw operations
Crane-assisted removal
Aerial lift operations
Other
Describe Other
Roadway safety mitigation
Is there exposure to vehicular traffic / roadway hazards at this job site?
*
Yes
No
Describe traffic control and roadway safety measures:
Cones
High-visibility clothing
Vehicle positioning
Signage
Flaggers
Spotters
Lane closures
Other
Describe Other
Additional Roadway Safety Mitigation Notes If Needed
Electrical hazard mitigation
Are there overhead electrical conductors at this job site?
*
Yes
No
Describe electrical hazard mitigation measures:
Minimum approach distance verification
Qualified personnel
Insulated tools
Insulated Blankets (low voltage only)
Dedicated spotter
Shutdown coordination
Other
Describe Other
Determine MAD based on qualification level
Avoid Contact
10'
1' 6"
2' 9"
2' 10"
3' 4'
Other
Public access mitigation
Is there potential exposure of pedestrians or the general public to the work area?
*
Yes
No
Public Access Mitigation Actions
Work is in an enclosed yard, communicate with customer to ensure they stay clear, utilize existing access controls such as fences
Utilize caution tape to control access to areas as needed
Position a spotter to watch for members of the public
Keep sidewalk clear of debris
Sidewalk closure
Other
Describe additional measures to control public access and protect pedestrians:
Ground conditions mitigation
Are uneven ground conditions, slopes, or trip hazards present at this job site?
*
Yes
No
Uneven Ground Conditions Mitigation
Use caution on slippery or uneven surfaces, go slowly and/or reduce carried load size
Mark hazards with cones
Temporarily relocate hazard
Place salt, soil, or other gripping agent to assist with traction
Modify route used to access the site
Other
Describe additional controls for uneven ground and trip hazards:
Adverse weather mitigation
Are adverse weather or environmental conditions expected during this operation?
*
Yes
No
Describe weather and environmental mitigation measures:
Heat: Stay hydrated and take brakes as needed
Cold: Dress warm, take brakes as needed, rewarm as needed
Wet: Wear rain gear, take brakes as needed, put on dry clothes as needed
Wind: Dress warm, rewarm as needed, cease aerial operations if necessary
Other
Describe Other
Underground utilities mitigation
Is excavation, digging, or ground disturbance planned near underground utilities?
*
Yes
No
Describe underground utility protection measures:
Falling object mitigation
Is there risk of falling objects or exposure to designated drop zones?
*
Yes
No
Describe controls for falling object and drop zone hazards:
Mark drop zone with drop zone cones (required)
Utilize verbal call and response before dropping material (required)
Utilize wireless communication devices such as SENA bluetooth (recommended)
Other
Describe Additional controls for falling object and drop zone hazards:
Mobile equipment mitigation
Will mobile equipment, cranes, lifts, or rotating machinery operate near personnel?
*
Yes
No
Describe controls for equipment movement and swing radius hazards:
Low visibility mitigation
Will work occur under limited visibility or low-light conditions?
*
Yes
No
Low visibility Mitigation
All crew members to wear high vis cloting
Crew lead to stop work when they determine there is insufficient light availaiblable to work safely
Augment site with additional lighting including truck hazard lights
Describe controls for limited visibility and lighting conditions:
Biological hazard mitigation
Are wildlife, insects, nesting animals, or biological hazards present at this site?
*
Yes
No
Describe mitigation measures for wildlife and biological hazards:
Restricted access mitigation
Is work being performed in confined or restricted access areas?
*
Yes
No
Describe controls for confined or restricted work areas:
Other mitigation steps
Are there any additional site-specific hazards not addressed above?
*
Yes
No
Describe mitigation measures for any additional hazards identified:
Hazard assessment and mitigation acknowledgment
I confirm that all identified hazards have been reviewed with the crew and that appropriate mitigation measures have been implemented prior to starting work.
*
Yes
No
3. Tree risk assessment
Only required if tree climbing or tree felling operations are occurring.
Tree 1 Description
Tree 2 Description
Tree 3 Description
Tree 4 Description
Tree 5 Description
Select all observed tree defects and risk indicators:
Rows
None observed
Dead or dying limbs
Dead or declining crown
Cracks or splits in trunk/leaders
Cavities or decay
Fungal conks / fruiting bodies
Excesive leaning / shifted root plate
Exposed or damaged roots
Included bark / weak unions
Previous failure points
Storm damage
Soil instability / erosion
Tree #1
Tree #2
Tree #3
Tree #4
Tree #5
Identify potential targets within striking distance:
Not applicable
None present
Vehicles
Buildings / structures
Power lines / utilities
Public / pedestrians
Roads / sidewalks
Landscaping / property features
Other
Describe Other
Overall tree risk level for this operation:
Rows
Low – No significant defects or targets
Moderate – Defects or targets present, manageable with controls
High – Significant defects and/or critical targets present
Severe – Imminent failure risk / unstable condition
Tree #1
Tree #2
Tree #3
Tree #4
Tree #5
For each tree rated High or Severe, describe the specific controls that will be implemented to reduce risk:
I confirm that the tree(s) were evaluated for defects and stability and that appropriate controls have been implemented based on the assessed risk if applicable.
*
Yes
No
I confirm that all climbing tie-in points have been visually inspected and appropriately pull tested / load tested prior to use, and that only verified anchor points will be used for life-support systems if applicable.
*
Yes
No
4. Personal Protective Equipment (PPE) Determination
Select all personal protective equipment required for this job:
*
Company approved footwear
Helmet / hard hat
Eye protection
Hearing protection
Cut-resistant leg protection when operating a chainsaw
Work Positioning Equipment
High visibility clothing and/or vest
Weather-specific PPE (rain gear, cold-weather gear, sun protection)
Respiratory protection
Fall protection
Other
Describe Other
I confirm that all required personal protective equipment has been inspected prior to use, is in good working condition, properly fitted, and free from defects that could affect safe performance.
*
Yes
No
5. Crew Acknowledgement and Electronic Signatures
Crew Member 1 Name
*
Daniel Wiener
Andrew Haggarty
Adam Keene
Sophia Nickerson
Allen Taylor
Elias Ditto
Other
Name if Other
Position
*
Crew Lead
Arborist
Arborist Trainee
Ground Worker
Equipment Operator
Other
Signature
Crew Member 2 Name
Daniel Wiener
Andrew Haggarty
Adam Keene
Sophia Nickerson
Allen Taylor
Elias Ditto
Other
Name if Other
Position
Crew Lead
Arborist
Arborist Trainee
Ground Worker
Equipment Operator
Other
Signature
Crew Member 3 Name
Daniel Wiener
Andrew Haggarty
Adam Keene
Sophia Nickerson
Allen Taylor
Elias Ditto
Other
Name if Other
Position
Crew Lead
Arborist
Arborist Trainee
Ground Worker
Equipment Operator
Other
Signature
Crew Member 4 Name
Daniel Wiener
Andrew Haggarty
Adam Keene
Sophia Nickerson
Allen Taylor
Elias Ditto
Other
Name if Other
Position
Crew Lead
Arborist
Arborist Trainee
Ground Worker
Equipment Operator
Other
Signature
Crew Member 5 Name
Daniel Wiener
Andrew Haggarty
Adam Keene
Sophia Nickerson
Allen Taylor
Elias Ditto
Other
Name if Other
Position
Crew Lead
Arborist
Arborist Trainee
Ground Worker
Equipment Operator
Other
Signature
Crew Member 6 Name
Daniel Wiener
Andrew Haggarty
Adam Keene
Sophia Nickerson
Allen Taylor
Elias Ditto
Other
Name if Other
Position
Crew Lead
Arborist
Arborist Trainee
Ground Worker
Equipment Operator
Other
By entering my name below, I acknowledge that I participated in this job safety briefing, understand the hazards and controls, and agree to follow all applicable safety procedures.
Signature
Crew Member 7 Name
Daniel Wiener
Andrew Haggarty
Adam Keene
Sophia Nickerson
Allen Taylor
Elias Ditto
Other
Name if Other
Position
Crew Lead
Arborist
Arborist Trainee
Ground Worker
Equipment Operator
Other
Signature
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