JOB SAFETY ANALYSIS (JSA)

SUPERVISOR:

EMAIL OF SUBMITTER:

PROJECT:

DATE:

TIME:

SITE REP:

EMERGENCY PHONE:

UNIT NAME / #:

JOB DESCRIPTION:

EMERGENCY INFORMATION

Weather:

Reviewed Alarms/Phones:

YES NO N/A

Reviewed Escape Route(s):

YES NO N/A

Describe:

Eyewash/Shower Location:

Evacuation Assembly Point:

WITNESSED or REPORTED ON PRIOR SHIFT?

Injury Near Miss Safety Violation Spill None Reported

People Involved:

Description:

PRE JOB ASSESSMENT

1. Atmospheric Testing?

Y N NA

2. Communicated Work?

Y N NA

3. Orientations Complete?

Y N NA

4. Proper Tools?

Y N NA

5. Rescue Plan Reviewed?

Y N NA

6. Reviewed MSDS?

Y N NA

7. Safety Equipment?

Y N NA

8. Scope Understood?

Y N NA

9. Valves Tagged Out?

Y N NA

10. Permit Issued?

YES NO N/A

Type:

Confined Space Crane Excavation Hot Work Pipeline Safe Work

AT RISK TEAM MEMBERS

Job New to Company Plant/Unit Upset

Team Members:

Experienced Partner:

IDENTIFY POTENTIAL HAZARDS

Abrasions Cave In Chemical Burn Cuts Dropped Objects Electrical Shock Elevated Work Fire Heat Stress Loud Noises Overexertion Overhead Work Particle in Eye Respiratory Slips/Trips/Falls Spills Sprains/Strains Thermal Burn

IDENTIFY HAZARD MITIGATION

Barricades Body Positioning Cotton/Leather Gloves Electrical Gloves Emergency Support Face Shield/Goggles Fall Arrest/Scaffold Fire Extinguisher/Hose Gloves/Task Appropriate Hearing Protection Housekeeping PPE Proper Tools Shoring/Sloping Spark Containment Subcontract Toe Boards/Netting Ventilation/Resp. Prot.

JOB SAFETY ANALYSIS (JSA) - PAGE 2

SPILL PREVENTION MEASURES

Containment Necessary?

Y N NA

Drains/Vents Closed?

Y N NA

Line ID Checked?

Y N NA

Lines Drained/Purged?

Y N NA

Low Points Drained?

Y N NA

Special Transfer Proc?

Y N NA

Spill Potential Reviewed:

Y N NA

PRIOR SHIFT COMPLETION REVIEW

1. Work Area Cleaned?

Y N NA

2. Red Tags/LOTO Released?

Y N NA

3. Permits Closed?

Y N NA

4. Status Communicated?

Y N NA

SIGNATURES

Foreman Signature:

Superintendent Signature:

ALL CREW MEMBERS SIGN BELOW

Signature indicates pre-job safety review attendance. Initials indicate no injuries to report at end of previous shift.

NAME (PRINT)

INITIALS

NAME (PRINT)

INITIALS