<p> COMPANY DAILY JOB SAFETY ANALYSIS (JSA) SUPERVISOR (Print Name): DATE: WORK LOCATION (BE EXACT): SHIFT (Circle one): 1 2 GENERAL TASK DESCRIPTION:</p><p>STEP 1. TASK ACTIVITY – LIST ALL BASIC JOB STEPS. USE ADDITIONAL SHEET IF NEEDED. 1 2 3 4 5 6 7 8 9 10 POTENTIAL HAZARD LIST (LIST ALL OTHERS NOT SHOWN) 1 Electrocution/Shock/Arc Flash 11 Vehicle Traffic 21 Poor Access to Work 31 Underground Utilities 2 Fall from Heights 12 Railway Traffic 22 Noise 32 Falling Objects & Debris 3 Overhead Work 13 Welding Fume 23 Flammable/Combustible Mat’l 33 Obstructed Vision 4 Lifting: Manual or Mechanical 14 Welding Arc 24 Fire 34 Power Lines 5 Rough / Sharp Material 15 Excavations 25 Compressed Air 35 Dehydration 6 Slippery / Uneven Surfaces 16 Lead Paint 26 Poor Lighting 36 7 Rotating / Moving Machinery 17 Asbestos 27 Confined Space 37 8 Hot Surfaces 18 Silica Dust 28 Chemical Exposure 38 9 Pinch / Crush / Nip Points 19 Inorganic Arsenic 29 Heat / Cold Stress 39 10 Flying Particles 20 Poor Work Position 30 Repetitive Motion 40</p><p>STEP 2. ENTER THE NUMBER CODE FOR EACH HAZARD FOR ALL JOB STEPS LISTED IN STEP 1 ABOVE. LIST ALL PREVENTION MEASURES & CORRECTIVE ACTIONS FOR EACH HAZARD. HAZARD NUMBER CORRECTIVE ACTIONS TAKEN TO ENSURE SAFETY CODE (USE ADDITIONAL SHEETS IF NEEDED)</p><p>STEP 3. SAFETY CHECKLIST - CHECK ALL ITEMS THAT APPLY TO YOUR JOB OR TASK. COMPANY DAILY JOB SAFETY ANALYSIS (JSA) Y N Y N Y N FIRE PROTECTION: PPE NEEDED: HAZARDOUS ENERGY CONTROL Fire Blanket or Plates Face Shield GFCI on All Circuits Welding Screens Monogoggles Lock-Out / Tag-Out Flammables Removed Hearing Protection Electric Tools/Cords Inspected Suitable Fire Extinguisher/Hose Gloves for Specific Hazard High Voltage Lines Identified LEL Measured Respiratory Protection Mechanical Energy Devices Secure Fire Watch on Duty Eye Wash Station/ Safety Shower Splash/Chemical Clothing HOUSEKEEPING: PERMITS NEEDED: Foot Protection/Metatarsal Guard Cords, Leads, Hoses Elevated 7 Ft. Hot Work Rubber Boots Trash/Scrap Containers Confined Space Entry Fall Protection Line Breaking Hi-Vis/reflective vest WORK PLATFORMS: Personnel Lift Basket Ladders Inspected Pre-Lift Rigging BARRICADES/WARNINGS: Scaffold OK for Use & Inspected Critical Lift Plan Caution (Yellow) Aerial/Scissor Lifts Inspected Excavation Danger (Red) Demolition Hard Barricade ABATEMENT NEEDED: Flashing Lights Lead Paint Air Horns / Sirens Asbestos</p><p>STEP 4. POST-TASK FOLLOW-UP – SUPERVISOR TO COMPLETE AFTER SHIFT/JOB ENDS. Job Start Time: All Lock & Tags Removed? YES NO NA Job End Time: Area Cleaned / Secured & Tools Stowed? YES NO List any other safety hazards found during the course of this job/task: Did any injuries occur? YES NO Supervisor’s Signature: If YES, who was injured? ______(sign here after ALL items are complete) X</p><p>CREW SIGN-IN BEFORE TASK CREW SIGN-OUT AFTER TASK I understand the safety precautions and have the I have worked safely today and have not been training to perform this task safely. injured.</p><p>SIGN THIS COLUMN AT SHIFT START SIGN THIS COLUMN AT SHIFT END</p>