JSA Fillable
Jobsite
Task Description
Date
Area of Jobsite
Evacuation Routes ID
Contractor
TYPE OF WORK
Concrete
Confined Space
Conveying Systems
Demolition
Drywall
Doors & WIndows
Earthwork
Electrical
Excavation
Finishing (lockers, Chalkboards, etc...)
Formwork
Furnishing (desk, chairs, etc.)
Heavy Equipment
Hot Work
Masonry
Material Handling
Mechanical
Pipe Fabrication
Rebar
Roofs / Ceilings
Scaffolding
Steel Erection
Thermal & Moisture Protection
Type option 24
Other
HAZARDS THAT EXIST
Air Born Particulates
Barricades Needed
Below Ground Hazards
Electrical Shock
Fall Hazards
Fire Hazards
Ground Fall Protection
Hand Tools (Right Tool For The Job)
Heat Stress (drinking water on site)
Heavy Objects (lifting)
High Noise Levels
Housekeeping Done Daily?
Hot/Cold Surfaces
Ladders (inspected, position right, etc...)
Material Storage and Handling
MSDS's (chemical hazards)
Overhead Hazards
Power Tools (inspected & guarded)
Restricted Access / Egress
Right Tool For Right Job
Restricted Lighting
Sharp Objects / Pinch Points
Slip & Trip Potentials
PPE
Safety Glasses (Required at all times)
Hard Hat (Required at all times)
Face Shield (Required Operating All Power Tools)
Goggles (Chemical Hazards)
Gloves
Hearing Protection
Fall Protection Plan
Foot Protection (No Athletic Shoes)
Respirator
Other
HEAVY EQUIPMENT NEEDED
Backhoe
Bobcat
Compactor
Crane
Dozer
Forklift
Man Aerial Lifts (All Types)
Track hoe
Grade All
Other
Can any of these happen to employees?
Struck Against
Caught In
Fall Same Level
Struck By
Caught On
Fall To Below
Contact With
Caught Between
Over Exertion
Contact By
Exposure
Heat Stress
Supervisor Full Name
Supervisor Signature
Names of Employees This Information Was Explained To (Name 1, Name 2, Name 3, etc...)
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