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Job Safety Analysis Worksheet

Project Information

Project Name: D

Project Location: Work A

Permit(s) Required Y/N: Permits Attached

Adjacent Work Y/NSee Permit Checklist Link to Permit List

JSA Type

Operations: New:

Transport: Revised:

Office: Other:

Construction:

Remediation:

Work Type: Work Ac

Equipment Checklist

Goggles: Lifeline/Body Harness: Supplied Respir

Face Shield: Hearing Protection: Air Purifying Respir

Safety Glasses: Hard Hat: Welding / Pipe Clot

Safety Shoes: Welding Mask / Goggles: Life

See Equipment Checklist Link to Equipment List Modify equipment list as needed

Job Steps Potential Hazard Hazard Mitgation Steps

Link to Hazard Checklist

Equipment Mob Setup Slips, Trips Secure area from trip hazards

Rebar puncture hazard Mark locations of rebar

Pinch Point Pinch point from equpment

Blind spots on equipment Maintain visual contact with operation

Excavation Swing / hit hazard Maintain safe distance from bucket

Pinch points Maintain clearance from equipment and drums

Chemical hazards Vapor and odor monitoring maintained as per workplan

High noise Hearing protection.Trackhoe stability Maintain rig on stable ground

Utilities Utility clearance OK

Vehicle traffic Maintain 10 MPH on all roads. Tire puncture hazard.

Hole collapse Maintain exclusion zone distance for work area

IDW handling Splatter from handling waste. Control splatter TEP

Bucket sampling Operate in visual contact with operator

Hole stability clearing debris Maintain safe WD with backhoe for clearing hole

Stockpile monitoring Stop excavation, maintain contact with operator

Foam Application Compressed air lines Secure lines from compressor

Spray hazard from foam Maintain spray away from personnel.

High noise Hearing protection.

Hazards of waste loading Maintain distance from equipment while loading waste

Environmental Control Limit waste generation as low as reasonably achievable

Team Member Signatures

Supervisor Signature: D

Instructions: Write the name of the job or task in the space provided.

Conduct a walk-through survey of the work area

Write work steps in a safe sequence

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Write work steps in a safe sequence

Permit Checklist Potential Hazard List

Utility clearance obtained

Soil excavation

Critical lift

Request for shutdown

Hot work

Confined space entry

Concrete scructure penetration Boom assembly, breakdown, proximity

Scaffold Erection plan Prop

Steel erection/decking/flooring/grating checklist Extin

Hoisting & rigging safety review Po

Electrically hazardous work

Pneumatic test

Radiation work permit

Required PPE

Hard hat

Ear protection

Eye Protection

Safety glasses

Face shieldChemical goggles

Welding hood

Hand Protection

Cut resistant gloves C

Welding gloves

Rubber gloves

Electrical insulated gloves

Arm sleves

Foot Protection

Safety shoes

Rubber boots

Boot covers

Dielectric footware

Fall protection

HarnessDouble lanyard required

Anchorage point available U

Respiratory Protection

Dust maks

Air purifying respirator

Supplied air respiator

SCBA

Emergency escape respirator

Protective Clothing

Coveralls I

Tyvek Pro

Nomex

Rainsuit

Acid suit

Confined SpaceAtmosphere Monitoring

Rescue Equipment

Rescue Service

Monitoring Equipment

PID/FID

O2/LEL

IH sampling

Respirable dust

Forms and Documents

Training records

Worker certifications and medical clearance

Written programs

Hazard assessments

Required OSHA postings, fact sheets, guides

Right to Know - MSDS - Hazcom - Prop 65 (CA)OSHA Tracking and compliance forms

DAILY TASK ANALYSIS W

o Hot Work / Welding

o Radiation

o Work Over/Near Water

o Confined Space Entry and Floor / Wall Openings

Housekeeping

Roadway / Traffic / Heavy Equipmento

o Electrical Hazards / Pressurized Lines

o Machines & Rotating Equipment

o

Spill Control and Containment

Site Security

o

o

o

o

Slips/Trips/Falls

Chemical Hazards

Medical Emergency

Manual Lifting

o

o

o

o

o

o

o

o

o

Pinch Points

Biological Hazards

Eye Hazards (i.e. projectiles, dust, gas)

Noise

Natural Hazards

Fire Hazards

o

o

Scaffolds & Ladders

Hand/Power Tools

Hand / Foot Hazards

Overhead Hazards

Heat/Cold Stress

Overhead Work

Drilling and boring

o Crane and Lifting Equipment

o

Excavation/Trenching Activities

o

o

o

o

o

Underground Utilities

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Project:

Task Location :

Task Description:

Observed by:

(1) ASSESS the risk.

What could go wrong?

What is the worst thing that can happen if something goes wrong?

(2) ANALYZE how to reduce the risk.

Is all necessary training and knowledge available to perform work safely?

Is all proper safety equipment, tools and PPE available?

(3) ACT to ensure safe operations.

Take necessary action to ensure the job is done safely.

Follow written procedures. Ask for assistance if necessary.

Cab cleanlieness Exiting cab

Window cleanliness Turning / cornering

Sounding horn Safe speed

Looking in reverse Dumping / lowering bed

Actions when approached Bucket actions

Seatbelt use Comm and eye contact

Follow pertinent procedures Material handling / locding

Proper PPE Follow pertinent procedures

Proper tool Awareness of equipment

Proper use of tools Housekeeping practices

Undersanding task

Working surfaces

Activities planned adequately Pre-task inspection

Crew prepared / briefed / trained Permits obtained as required

Hazards controls adequate Traffic controls / signs / route

Behavior Based Safety Observations

Safety Assessment Checklist

Risk Severity Scale

Additional Hazards / Observations

Safe = 1 2 3 4 5 = At Risk

Rate each observation below for risk potential (1 to 5) 0 = not

Operators

Field Crew and Labor

Supervisors and Managers

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Explanation of At-Risk Behaviors

Explanation of Good Behaviors

Corective Actions

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Date:

Duration Observed:

Proper PPE

Working on slopes

Awareness of surroundings

Walkaround / inspections

Turn signal use

Qualified on equipment

Distractions

Approaching equipment

Grasping / handling

Balance / body position

Lifting

Task simple by design

Adequate safety administration

Ergonomics

applicable

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Safety Prevention Checklist (Daily Completion by Supervisor)

Supervisor:

ContractorNumber of Employees for the

day:

Site:______________________________________________Frequency Saturday

Ensure Project Safety Plan is in place Daily

Understand Scope of Work Daily

Identify all hazards Daily

Complete all required permits Daily

Ensure crew is properly trained Daily

Communicate hazards to all crew members Daily

Ensure any required hazardous energy control Daily

Ensure equipment is available and in proper working order Daily

Hold morning safety meeting Daily

Ensure staffing is adequate Daily

Ensure other employers are informed of potentially hazardous activities that might affect them Daily

Ensure locator services have been contacted to identify any underground obstructions Daily

Supervisor's Daily Safety Prevention Score:

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Employee's Daily Safety Card DateCard Holder:

Company:

Supervisor:Do you understand the Project Safety Plan? (y/n)

Do you know the Scope of Work? (y/n)

Have you identified all hazards? (y/n)

Are all work permits completed for your work?

Are you properly trained for safety?

Do you know all the potential hazards around you?

Is hazardous energy control complete?

Is your equipment available and working properly?

Did you attend the morning safety meeting?

Do you have sufficient co-worker assistance?

Have you informed employees of your potentially hazardous work?

Have locator services been informed of your underground work?

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Employee's Daily Safety CardCard Holder:

Supervisor:

Contractor:Do you understand the Project Safety Plan? (y/n)

Do you know the Scope of Work? (y/n)Have you identified all hazards? (y/n)

Are all work permits completed for your work?

Are you properly trained for safety?

Do you know all the potential hazards around you?

Is hazardous energy control complete?

Is your equipment available and working properly?

Did you attend the morning safety meeting?

Do you have sufficient co-worker assistance?

Have you informed employees of your potentially hazardous work?

Have locator services been informed of your underground work?

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Employee's Daily Safety CardCard Holder:

Supervisor:

Contractor:Do you understand the Project Safety Plan? (y/n)

Do you know the Scope of Work? (y/n)Have you identified all hazards? (y/n)

Are all work permits completed for your work?

Are you properly trained for safety?

Do you know all the potential hazards around you?

Is hazardous energy control complete?

Is your equipment available and working properly?

Did you attend the morning safety meeting?

Do you have sufficient co-worker assistance?

Have you informed employees of your potentially hazardous work?

Have locator services been informed of your underground work?

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No. Contractor List

Employees Company

1

2

3

45

Add additional lines as needed. Link to individual sheets for summary tabulation by contractor.

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Company Acronym Title Supervisor

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Date Hours Worked

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Injury Reports 2005Case No. Injured Company Date of Injury

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Nature of Injury Severity Days of Work Missed

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Responsible Manager

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Injury Report for:Company Name:

Supervisor:

Site:Case No.#:

Injury Date:

Nature of Injury:

Severity:

Treating Clinic:

Hospital Physicians Contact Information:

Days of Work Missed:

Location of Injury:

Specific Work Being Performed at Occurrence:

Nature of Supervision at Accident:

Causal Factors (Events and conditions that

contributed to the accident):

Corrective Actions (Actions that have or will be

taken to address the hazard and prevent

reoccurrence):

Prepared By:

Title:

Date:

Signature:

Responsible Manager:

Title:

Date:

Signature:

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Safety Statistics 2005 Site Name

Contractor____________

Category Jan Feb March April MayContractor Days Away From Work Rate 2005

Contractor OSHA Recordable Rate 2005

Total Contractor On-Site work hours

Total Sub Contractor On-Site work hours

Total Contractor Off-Site work hours

Number of OSHA Recordable Incidents for Contractor

Number of Days Away from Work (DAWF) for Contractor

Number of OSHA Recordable Incidents for Subcontractors

Number of Days Away from Work (DAWF) for SubContractor

Fatalities

First Aids Cases

Reportable SpillsFires

Motor Vehicle Accidents (MVA)

Notice of Violations (NOV)

Media Coverage

Repetitive Stress Injury (RSI)

Third Party Liability Event

Contractor____________

Category Jan Feb March April May

Contractor Days Away From Work Rate 2005

Contractor OSHA Recordable Rate 2005

Total Contractor On-Site work hours

Total Sub Contractor On-Site work hours

Total Contractor Off-Site work hours

Number of OSHA Recordable Incidents for Contractor

Number of Days Away from Work (DAWF) for Contractor

Number of OSHA Recordable Incidents for Subcontractors

Number of Days Away from Work (DAWF) for SubContractor

Fatalities

First Aids Cases

Reportable Spills

Fires

Motor Vehicle Accidents (MVA)

Notice of Violations (NOV)Media Coverage

Repetitive Stress Injury (RSI)

Third Party Liability Event

Contractor____________

Category Jan Feb March April May

Contractor Days Away From Work Rate 2005

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Contractor OSHA Recordable Rate 2005

Total Contractor On-Site work hours

Total Sub Contractor On-Site work hours

Total Contractor Off-Site work hours

Number of OSHA Recordable Incidents for Contractor

Number of Days Away from Work (DAWF) for Contractor

Number of OSHA Recordable Incidents for SubcontractorsNumber of Days Away from Work (DAWF) for SubContractor

Fatalities

First Aids Cases

Reportable Spills

Fires

Motor Vehicle Accidents (MVA)

Notice of Violations (NOV)

Media Coverage

Repetitive Stress Injury (RSI)

Third Party Liability Event

Contractor____________Category Jan Feb March April May

Contractor Days Away From Work Rate 2005

Contractor OSHA Recordable Rate 2005

Total Contractor On-Site work hours

Total Sub Contractor On-Site work hours

Total Contractor Off-Site work hours

Number of OSHA Recordable Incidents for Contractor

Number of Days Away from Work (DAWF) for Contractor

Number of OSHA Recordable Incidents for Subcontractors

Number of Days Away from Work (DAWF) for SubContractor

Fatalities

First Aids CasesReportable Spills

Fires

Motor Vehicle Accidents (MVA)

Notice of Violations (NOV)

Media Coverage

Repetitive Stress Injury (RSI)

Third Party Liability Event

Contractor____________Category Jan Feb March April May

Contractor Days Away From Work Rate 2005

Contractor OSHA Recordable Rate 2005Total Contractor On-Site work hours

Total Sub Contractor On-Site work hours

Total Contractor Off-Site work hours

Number of OSHA Recordable Incidents for Contractor

Number of Days Away from Work (DAWF) for Contractor

Number of OSHA Recordable Incidents for Subcontractors

Number of Days Away from Work (DAWF) for SubContractor

Fatalities

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First Aids Cases

Reportable Spills

Fires

Motor Vehicle Accidents (MVA)

Notice of Violations (NOV)

Media Coverage

Repetitive Stress Injury (RSI)Third Party Liability Event

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June July Aug Sept Oct Nov Dec Total0

0

0

0

0

0

0

0

0

0

0

00

0

0

0

0

0

June July Aug Sept Oct Nov Dec Total

0

0

0

0

0

0

0

0

0

0

0

0

0

0

00

0

0

June July Aug Sept Oct Nov Dec Total

0

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0

0

0

0

0

0

00

0

0

0

0

0

0

0

0

0

June July Aug Sept Oct Nov Dec Total

0

0

0

0

0

0

0

0

0

0

00

0

0

0

0

0

0

June July Aug Sept Oct Nov Dec Total

0

00

0

0

0

0

0

0

0

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0

0

0

0

0

0

00