JSA Form - Job Safety Analysis Checklist

The JSA Form - Job Safety Analysis Checklist helps assess and identify hazards in your workplace through inspections of chemical use, electrical systems, etc.

JSA Form - Job Safety Analysis Checklist



Job Safety Analysis

1. Was chemical use checked to ensure safety using one or more of the following methods? •Emergency shower identified and available •IH Sample Plan •Eye wash station (identified/available) •Respiratory Protection Form (Site Form A-6005-593) •Portable eyewash w/drench hose (Number of units required for work activity): •Dermal PPE •Chemical Boots •Ventilation •Chemical Gloves •Chemical Goggles


Photo Comment

2. Was potential contact with tank waste checked to ensure safety using one or more of the following methods? •Emergency shower identified and available •Pipe / Vessel purged, drained, flushed •Portable eyewash w/drench hose (Number of units required for work activity): (include text here) •Pipe / Vessel breach point containment •Pipe / Vessel depressurized •Pipe / Vessel isolated •Chemical Gloves •Dermal PPE


Photo Comment

3. Was potential contact with process chemicals checked to ensure safety using one or more of the following methods? •Emergency shower identified and available •Pipe / Vessel breach point containment •Eye wash station (identified/available) •Respiratory Protection Form (Site Form A-6005-593) •Portable eyewash w/drench hose (Number of units required for work activity): •Pipe / Vessel purged, drained, flushed •Chemical Boots •Pipe / Vessel depressurized •Chemical Gloves •Pipe / Vessel isolated •Chemical Goggles •Ventilation •IH Sample Plan •Dermal PPE


Photo Comment

4. Was RAD Risk Screening and development of appropriate controls performed in accordance with TFC-OPS-MAINT-C-01 and TFC-ESHQ-RP-RWP-C-03 for radiological safety?


Photo Comment

5. Were tank form vapors checked to ensure safety using one or more of the following methods? •Tank Vapors Information Sheet (TVIS) # •Respiratory Protection Form (Site Form A-6005-593) •IH Sample Plan •Similar Exposure Group


Photo Comment

6. Was asbestos checked to ensure safety using one or more of the following methods? •Asbestos Work Permit •IH Sample Plan


Photo Comment

7. Was lead checked to ensure safety using one or more of the following methods? •Lead Compliance Plan •IH Sample Pla


Photo Comment

8. Were electrical controls checked to ensure safety using one or more of the following methods? • EEWP • EHE


Photo Comment

9. Was the confined space hazard checked to ensure safety using one or more of the following methods? •Confined Space Hazard Identification •Non-Permit Confined Space Controls •Confined Space Entry Permit •IH Sample Plan


Photo Comment

10. Were rotating/moving equipment or pinch points checked to ensure safety using one or more of the following methods? •Block parts against motion


Photo Comment

11. Was noise >85 dBA checked to ensure safety using one or more of the following methods? •Noise Barrier •Hearing Protection Boundary •IH Sample Plan # Hearing Protection Specify


Photo Comment

12. Were crane or other lifting equipment lifting and rigging objects checked to ensure safety using one or more of the following methods? •Special Lift •Critical Lift •Utility Notification •EU notification


Photo Comment

13. Were vehicular traffic, equipment, and/or forklifts checked to ensure safety using one or more of the following methods? •Lane Closure


Photo Comment

14. Were elevating work platforms checked to ensure safety using one or more of the following methods? •Lane Closure •Cones •Fall Protection Work Permit •Signs •Traffic Barricades


Photo Comment

15. Were overhead utilities checked to ensure safety using one or more of the following methods? •De-energizing req. •Insulation blankets req. •Wire watch req. •Req. clearance distance •Safe work zone marked •Electrical Utility Notification


Photo Comment

16. Were falls/roof work checked to ensure safety using one or more of the following methods? •Engineering Evaluation •Fall Protection Work Permit (Site Form A-6004-286) •Fall Protection Equipment Pre-Use Inspection


Photo Comment

17. Was scaffolding checked to ensure safety using one or more of the following methods? •Fall Protection Work Permit


Photo Comment

18. Were moving/falling objects from heights checked to ensure safety using one or more of the following methods? •Barricade around potential fall area •Warning Signs


Photo Comment

19. Were excavations, trenching, shoring, and soil contamination checked to ensure safety using one or more of the following methods? •Site Excavation Permit •Ground Scans •Barricades


Photo Comment

20. Were underground utilities (line locating) checked to ensure safety using one or more of the following methods? •Ground Scan •Voltage rated gloves •Insulated hand tools •Maintain clearance distance •Safe work zone marked •Site Excavation Permit •Underground Electrical Utilities (Site Form A-7400-373)


Photo Comment

21. Was fire hazard weld, burn, grind, or solder checked to ensure safety using one or more of the following methods? •Respiratory Protection •Hot Work Permit •Fire Blanket •Welding Screen IH Sample Plan Fire Marshall Permit


Photo Comment

22. Was hazardous energy (air/steam/fluid/pressurized) checked to ensure safety using one or more of the following methods? •Depressurize •Sleeving •Cool down systems


Photo Comment

23. Was stored energy checked to ensure safety using one or more of the following methods? •Barricade Work Area •Remove Energy


Photo Comment

24. Were eye, foot, head, and hand hazards checked to ensure safety using one or more of the following methods? •Face Shield •Goggles •Cut Resistant Gloves •Heat Resistant Gloves


Photo Comment

25. Was wall ceiling blind penetration checked to ensure safety using one or more of the following methods? •Area Scan where penetration will take place


Photo Comment

26. Were tank vapor flammable/explosive hazards checked to ensure safety using one or more of the following methods? •Ignition Source Control Screening


Photo Comment

27. Were laboratory hazards (e.g., chemical splashes, chemical compatibility, reactive, time-sensitive) checked to ensure safety using one or more of the following methods? •Chemical Segregation •Volume Limitations •Fume Hoods •Special Labeling or Postings •IH Sample Plan •Lab Coat


Photo Comment

28. Was heat stress due to localized heat source or special PPE use checked to ensure safety using one or more of the following methods? •Heat Stress Mitigation Checklist


Photo Comment

29. Was the removal of abandoned/deactivated equipment checked to ensure safety using one or more of the following methods? •Air Gaps •Containment •Flushing •Drain/Depressurize •Hot Tap •Remove Stored Energy


Photo Comment

Is this sample what you are looking for?
Sign up to use & customise this template, or create your own custom checklist:

Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

Seeing is Believing

Get a live demo customized to your unique needs, or get started with a 14-day FREE trial.