Job Safety Assessment (JSA)
6G MSI
Date
-
Month
-
Day
Year
Date
Your Name
First Name
Last Name
Your Email
example@example.com
Your Company Name
Site Name
Muster Area
Permits Required
None
Hot Work
Excavation
Lock Out/Tag Out
Confined Space
Job to be Performed
Job Tasks
Job Hazards & Controls
Check all that apply and give details as needed in the Tasks, Hazards and Controls section of this form
Safety Orientation
Workers have completed the 6G MSI and Client Safety Orientation
Other
Stop Work
Every worker understands the obligation to stop unsafe acts or conditions
Work Area Hazards
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
Housekeeping
Job location clean and free of hazards
Clutter on job site
Garbage on ground
Signage present as necessary
Are tools and equipment clean and orderly
Task Hazards
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
Personal Protective Equipment (PPE)
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
Emergencies & Communication
Communication resources available to call for help, if needed
Site Specific Safety Plan available
Hand held radios charged and in working order
Alarms working
Horns working
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
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
Heavy Equipment Concerns
Current operator certification on file
Equipment daily inspections completed Equipment swing radius clear
Positioning and outrigger location addressed Overhead power lines, utilities, etc.
Air horn or other communication
Signal man or spotter
Pinch points or caught between
Soft, hard, muddy, wet, sloped ground
Area cordoned off
Other
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
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
Hot Work
Fire extinguishers at job location
Fire watch identified
Flammables, combustibles or LEL concerns controlled
Fire blanket necessary
Ground lead as close to weld as possible
Proper work attire
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
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
Environmental Issues
Spill prevention and control measures in place
Safety Data Sheets are available at www.6gmsi.co
Other
Additional Hazards
Additional Controls
Workers Present
Visitors
Signature of Workers
Submit
Should be Empty: