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JOB SAFETY ANALYSIS (JSA) FORM

Complete

Score 76% Flagged items 0 Actions 0

Audit Title  

Document No. 000001

Client / Site  

Conducted on 02.03.2023

Prepared by Arif khan

Location

Personnel  

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1.Audit-76%
Audit 76%  
1.1.siteinformation
 
site information  

work order number  

sqe

task activity  

qe

date

Site number/Name  

qe

name of contractor/Subcontractor  

qe
1.2.checkapplicableanticipatedorpotentialhazards-66.67%
 
check applicable anticipated or potential 66.67%
hazards

Demolition Safe

Underground tank removal/Disposable/High vapors At Risk

Activities in or near traffic areas Safe

Concrete cutting or coring Safe

Mobile heavy equipment activity (excavators, dump trucks,

At Risk
vacuum and hydovac trucks)

Pile driving / shoring Safe

Work affecting integrity of critical controls At Risk

Welding, cutting, grinding Yes

Hydoblasting / sand blasting No

Radiography / X-Ray testing Yes

pressure testing Yes

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Other (specify) : Yes

1.3.criticalprocedures:whereworkinvolvesanyofthefollowinghazardsmustbeincorporatedintoJSA-71.43%
 
critical procedures: where work involves
any of the following hazards must be 71.43%

incorporated into JSA

Work at heights above 1.5m Yes

Confined space entry (includes tank cleaning) No

Electrical/Mechanical lockout (live, isolation, lock out / tag out Yes

Heavy equiptment lifting (cranes, boom trucks, excavators) Yes

Drilling borehole / excavations (Sub-surface clearance,

Yes
locates)

Entry into excavations/Trenches > 1.2 m (4ft) deep No

Hot work (in potentially explosive atmosphere) Yes

1.4.ensureallhazardsidentifiedareaddressedinJSAbelow
 
ensure all hazards identified are addressed  
in JSA below

1. sequence of basic job Step in order  

1.potential hazards. (Ex. underground services, hazard zone

 
etc.)

1.safety controls to reduce or eliminate hazard  

2. sequence of basic job Step in order  

2. potential hazards. (Ex. underground services, hazard zone

 
etc.)

2. safety controls to reduce or eliminate hazard  

3. sequence of basic job Step in order  

3. potential hazards. (Ex. underground services, hazard zone

 
etc.)

3.safety controls to reduce or eliminate hazard  

4. sequence of basic job Step in order  

4. potential hazards. (Ex. underground services, hazard zone

 
etc.)
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4.safety controls to reduce or eliminate hazard  

5. sequence of basic job Step in order  

5. potential hazards. (Ex. underground services, hazard zone

 
etc.)

5.safety controls to reduce or eliminate hazard  

1.5.tools/Equipment(listoftoolsandequipmentandtheirstorageonsite,ifrelevanttosafety-100%
 
tools / Equipment ( list of tools and
equipment and their storage on site, if 100%

relevant to safety

List Yes
1.6.additionalPPE(minimumrequirement:safetyboots,hardhat,visi-vest,glasses,gloves)-100%
 
additional PPE ( minimum requirement:
safety boots, hard hat, visi-vest, glasses, 100%

gloves)

Eye protection Yes

Hearing protection Yes

Fall protection Yes

Rubber footwear and gloves if in a damp area Yes

Portable gas monitor Yes

Other (fire retardant coveralls, breathing apparatus, etc)

 
specify :
1.7.outsideauthorities:
 
outside authorities:  

outside authorities  

wf
02.03.2023 17:55 +03
1.8.disposalofdesignatedsubstances,surplus,orimpactedmaterials(disposaldetails,e.gwhen,where,how?)
 
disposal of designated substances, surplus,
or impacted materials (disposal details, e.g  

when, where, how?)

 

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1.9.retailer/Salesassociate
 
retailer/Sales associate  

prepared by  

date

person carrying out work  

date

person carrying out work  

date

person carrying out work  

date
1.10.sitesupervisor
 
site supervisor  

JSA approved retailer/Sales associate signature  

date

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