Transcription of Job Safety Analysis (JSA) Form - buckeyelivesafe.com
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Job Safety Analysis (JSA) Form - buckeyelivesafe.com
SA B-14 form A Job Safety Analysis (JSA) 6/15 JOB Safety Analysis (JSA) Date/Time: Location: (Step 1) Work Area: Work Order No: Work Description (include Tank, Pipeline and Equipment Numbers as Practical): (Step 2) PROCEDURE REVIEW (Step 10) JSA Developer Have the relevant Procedures and Standards, been reviewed? Yes Pending confirmation by the Buckeye PIC of site conditions, I agree that the attached JSA identifies the significant Task Steps, hazards , and Hazard Controls. (Step 8) RISK ASSESSMENT Must existing Procedures or Work Practices be modified to perform this work? (Procedure Deviation Approval Required) Yes No JSA Team Leader: Signature: PIC Name: Signature: After mitigation, are there any hazards that continue to present a potentially significant risk?
SA B-14 Form A – Job Safety Analysis (JSA) 6/15 (Step 6) JOB SAFETY ANALYSIS – WORK HAZARD ASSESSMENT FORM This table of Hazards and Controls can assist the work group to manage hazards for the proposed work. The table does not include all possible hazards. It is expected that the required PPE for the activity and work conditions will be used.
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