Job Safety Analysis Worksheet

Project Information
Project Name:

Date:

Project Location:

Work Area:

Permit(s) Required Y/N:

Permits Attached Y/N

Adjacent Work Y/N

See Permit Checklist
JSA Type

Link to Permit List

Operations:
Transport:
Office:
Construction:
Remediation:

New:
Revised:
Other:

Work Type:

Work Activity:

Equipment Checklist
Goggles:
Face Shield:
Safety Glasses:
Safety Shoes:
See Equipment Checklist
Job Steps
Equipment Mob Setup

Excavation

Lifeline/Body Harness:
Hearing Protection:
Hard Hat:
Welding Mask / Goggles:
Link to Equipment List
Potential Hazard
Link to Hazard Checklist
Slips, Trips

Modify equipment list as needed

Hazard Mitgation Steps

Rebar puncture hazard

Pinch Point
Blind spots on equipment

Mark locations of rebar

Pinch point from equpment
Maintain visual contact with operation

Swing / hit hazard

Pinch points
Chemical hazards
High noise
Trackhoe stability
Utilities
Vehicle traffic
Hole collapse
IDW handling
Bucket sampling
Hole stability clearing debris

Maintain safe distance from bucket

Maintain clearance from equipment and drums
Vapor and odor monitoring maintained as per workplan
Hearing protection.
Maintain rig on stable ground
Utility clearance OK
Maintain 10 MPH on all roads. Tire puncture hazard.
Maintain exclusion zone distance for work area
Splatter from handling waste. Control splatter TEP
Operate in visual contact with operator
Maintain safe WD with backhoe for clearing hole
Stop excavation, maintain contact with operator

Stockpile monitoring

Foam Application

Compressed air lines

Spray hazard from foam
High noise

Hazards of waste loading

Environmental Control

Supplied Respirator:
Air Purifying Respirator:
Welding / Pipe Clothing:
Life Vest:

Required Tools / Material for Safe Work

Secure area from trip hazards

Secure lines from compressor

Maintain spray away from personnel.
Hearing protection.
Maintain distance from equipment while loading waste
Limit waste generation as low as reasonably achievable

Team Member Signatures

Supervisor Signature:

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
List all possible hazards in each step including possibility for failure
In the Hazard Mitigation Checklist (page 2) provide actions taken to keep the hazard from resulting in accident or injury
List tools and additional equipment needed for safe work.
Have teammembers sign in spaces provided
Review Task Analysis for changes and improvements
Stop Work and complete new safety analysis if conditions change or deficient safety observation is noted.

Gloves:
Other:
Other:
Other:

Date:

DAILY TASK ANALYSIS WORKSHEET

Permit Checklist
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
Steel erection/decking/flooring/grating checklist
Hoisting & rigging safety review
Electrically hazardous work
Pneumatic test
Radiation work permit

Required PPE
Hard hat
Ear protection
Eye Protection
Safety glasses
Face shield
Chemical goggles
Welding hood
Hand Protection
Cut resistant gloves
Welding gloves
Rubber gloves
Electrical insulated gloves
Arm sleves
Foot Protection
Safety shoes
Rubber boots
Boot covers
Dielectric footware
Fall protection
Harness
Double lanyard required
Anchorage point available
Respiratory Protection
Dust maks
Air purifying respirator
Supplied air respiator
SCBA
Emergency escape respirator
Protective Clothing
Coveralls
Tyvek
Nomex
Rainsuit
Acid suit
Confined Space
Atmosphere 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

Potential Hazard List

o

Housekeeping

Slips/Trips/Falls

Pinch Points

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

Fire Hazards

Chemical Hazards

Hand / Foot Hazards

Noise

Manual Lifting

Heat/Cold Stress

Natural Hazards

Biological Hazards

Roadway / Traffic / Heavy Equipment

Medical Emergency

Spill Control and Containment

Site Security

Underground Utilities

Electrical Hazards / Pressurized Lines

Hand/Power Tools

Machines & Rotating Equipment

Drilling and boring

Overhead Work

Overhead Hazards

Scaffolds & Ladders

Crane and Lifting Equipment

Excavation/Trenching Activities

Work Over/Near Water

Confined Space Entry and Floor / Wall Openings

Hot Work / Welding

Radiation

Hazard Mitigation Checklist

Appearance neat & orderly o
Regular removal of trash o
Inspect for Hazards o
Work zone free of debris o
List potential pinch points o
Working near equipment o
Safety glasses o
Face shield o
Proper extinguishers and number o
Extinguishers inspected & visible o
Potential for contact, inh, injest o
Identified chemicals o
Sharp tools, materials, equip o
PPE, gloves, guards in place o
Ear plugs o
Ear muffs o
Reviewed proper lifting o
Weight for mechanical lifting o
H/C Temperature monitoring o
Review heat/cold symptoms o
Animal, insect hazards o
Snake chaps required o
Bloodborne pathogens o
Mold, fungus, spores o
Traffic cones & signs o
Communication with operator o
First-Aid Kit o
Hospital / clinic secured o
Spill plan in place o
Booms and absorbent o
Gates and fences secure o
Security services secured o
One call performed o
Dig permit received o
Permit required o
Lockout - Tagout o
Safe use reviewed o
GFCI in use o
Understand machine process o
Identify and mark hazards o
Equipment in good order o
Safety equipment in place o
Safety harness o
Rigid railing required o
De-energization required o
____(ft) Clearance distance o
Inspect for general conditions o
Proper placement / angle / tieoff o
Lifting equipment inspected o
Tag lines in use o
Permits in place o
Barricades o
Personal floatation devices o
Safety / lifelines o
Permit in place o
LEL / O2 meters o
Permits in place o
Fire extinguishers o
Work permit in place o
Isotopes identified o
Additional Information

Passageway & walkways clear

Portable toilets maintained
Hazards marked
Cords secured
Hand, body position

o
o
o
o
o

Goggles
Eye wash station available
Safety cans for gas/diesel
Smoking area assigned
Identified proper PPE
Identified proper monitoring
Safety equipment

o
o
o
o
o
o
o

Wash station available o

Additional information below o

Other information below o
Smoke detectors in buildings

Monitoring equipment o
Hand protection required o
Cool-down / warm-up period
Break area / fluids available
Poison plants
Lightning / weather
Sewage or medical waste
Animal / human waste / carcasses
Flagmen
Lane closure
Emerg nbrs / directions posted
FA/CPR Competent person
Fuel and chem tanks bermed
ESD identified
Security devices and alarms
Locks and chains
Subsurface survey complete
Safe zone marked
Confirm de-energized
Review safety procedures
Guards OK
Additional information below
Training and working procedures
Emergency shut off identified
Hazards identified
Support equipment ready
Warning signs required
Barricade tape
Wire watcher required
Safe zone marked
Tags in place
Footing sound and level
Personnel clear of overhead load
Signalman assigned
Proper sloping / shoring
Protection from water
Liferafts / lifeboat available

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Safety watch in place

Rescue in place
Flammable debris removed
Fire watch
Survey / monitoring instruments
Dosimetry required

o
o
o
o
o
o

Additional information below o

o
Disease causing pathogens

Additional information below o

Rally point identified o
Additional information below o
Additional information below o
Chemicals locked and secure o
Reviewed as-builts o
Down electrical lines o

Guards in place
Additional information below
Ground stable / level
Additional information below
Lanyards required

o
o
o
o
o

Additional information below o

Guard rails and toe boards o
Additional information below o
Work area barricaded o
Inspected prior to entry o
Access / egress provided o
Additional information below o
Hazards marked and barricaded
Additional information below
Hot areas / items identified
Proper PPE identified
Additional information below

o
o
o
o
o

Behavior Based Safety Observations

Project:
Task Location :
Task Description:
Observed by:
Safety Assessment Checklist
(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.
Risk Severity Scale
Safe = 1 2 3 4 5 = At Risk
Rate each observation below for risk potential (1 to 5) 0 = not applicable

Cab cleanlieness
Window cleanliness
Sounding horn
Looking in reverse
Actions when approached
Seatbelt use
Follow pertinent procedures

Proper PPE
Proper tool
Proper use of tools
Undersanding task
Working surfaces

Operators
Exiting cab
Turning / cornering
Safe speed
Dumping / lowering bed
Bucket actions
Comm and eye contact
Material handling / locding
Field Crew and Labor
Follow pertinent procedures
Awareness of equipment
Housekeeping practices

Supervisors and Managers

Activities planned adequately
Crew prepared / briefed / trained
Hazards controls adequate

Pre-task inspection
Permits obtained as required
Traffic controls / signs / route

Additional Hazards / Observations

Explanation of At-Risk Behaviors

Explanation of Good Behaviors

Corective Actions

ns
Date:
Duration Observed:

sk
to 5) 0 = not applicable

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

Safety Prevention Checklist (Daily Completion by Supervisor)

Supervisor:

Contractor

Number of Employees for the

day:

Site:______________________________________________
Ensure Project Safety Plan is in place
Understand Scope of Work
Identify all hazards
Complete all required permits
Ensure crew is properly trained
Communicate hazards to all crew members
Ensure any required hazardous energy control
Ensure equipment is available and in proper working order
Hold morning safety meeting
Ensure staffing is adequate
Ensure other employers are informed of potentially hazardous activities that might affect them
Ensure locator services have been contacted to identify any underground obstructions

Frequency
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily

Supervisor's Daily Safety Prevention Score:

Wednesday, November 02, 2016

y
y
y
y
y
y
y
y
y
y
y
y

Employee's Daily Safety Card

Card 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?

Date

Employee's Daily Safety Card

Card 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?

Employee's Daily Safety Card

Card 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?

No.

Contractor List
Employees

Company

1
2
3
4
5

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

Company Acronym

Title

Supervisor

Date

Hours Worked

Injury Reports 2005

Case No.

Injured

Company

Date of Injury

Nature of Injury

Severity

Days of Work Missed

Responsible Manager

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:

Safety Statistics 2005

Site Name
Contractor____________
Category
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

Jan

Feb

March

April

May

Jan

Feb

March

April

May

Contractor____________
Category
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
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

Jan

Feb

March

April

May

Jan

Feb

March

April

May

Jan

Feb

March

April

May

Contractor____________
Category
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
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

June

July

Aug

Sept

Oct

Nov

Dec

Total
0
0
0
0
0
0
0
0
0
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
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
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
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
0
0
0
0
0
0
0
0