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Doc. ID: OHS-F-02 Revision No.: 03 Date of Revision: 21st September, 2021 No. of Pages: Page 1 of 2
TASK LOCATION TYPE OF TASK DATE (DD/MM/YYYY) CLIENT LOCATION (IF APPLICABLE) JSA NO.
Generic New JSA-001
2. Lifting something In addition to using proper lifting techniques it is important to communicate with your others to
with a partner coordinate lifting, moving, and lowering objects with prearranged signals (on the count of three).
Doc. ID: OHS-F-02 Revision No.: 03 Date of Revision: 21st September, 2021 No. of Pages: Page 2 of 2
H/M/L= High/Medium/Low
Safety Glasses Goggles Safety Harness Lifting Precaution Rope Off Area Fire Extinguishers
Coveralls Chemical gloves Hot Work Permit Vessel Entry Permit Barricades Fire Watch
I understand and will adhere to the steps, hazards and controls as described in this JSA. I understand that performing steps out of sequence may pose hazards that have not been evaluated, nor
authorized. I will contact my Supervisor prior to continuing work, if the scope of work changes or new hazards are introduced. I understand I have the authority and responsibility to stop work I
believe to be unsafe.
TEAM MEMBERS
NAME SIGNATURE DATE NAME SIGNATURE DATE
SUPERVISIOR ACCEPTANCE
I have reviewed the steps, hazards & controls described in this JSA with all workers listed above & authorize them to perform the work. Workers are qualified (i.e. years of
experiences or trained) to perform this activity.
PRINT NAME: SIGNATURE: DATE: