FER JSA Report

Job Safety Analysis (JSA)

Description of Work:

Site Location/Unit:

Equipment Type:

Date:

Muster Point:

Wind Direction:

Weather Condition:

Safety Shower Location:

Team Member Names (Print)

Basic Job Steps	Hazards	Mitigation Methods

REPORT ALL NEAR MISSES, INJURIES, AND INCIDENTS TO YOUR SUPERVISOR

Was task performed safely with no injuries and/or incidents? Yes No If NO, report immediately to Supervisor

EMPLOYEE SIGN-OFF

All employees MUST sign before starting work.
I have read and understand the JOB HAZARD ANALYSIS and PERMIT and agree to adhere to all safety precautions and procedures to complete this job safely. If any part of my task plan changes or new hazards exist, I will alert my supervisor to modify the JSA.

Employee 1:

Signature (draw below):

Employee 2:

Signature (draw below):

Employee 3:

Signature (draw below):

Lead / Supervisor Signature

Name:

Signature (draw below):

Date:

END OF TASK CHECKLIST

Permit turned in?	Yes N/A Extended
Area Cleaned Up?	Yes N/A
Barricades Removed?	Yes N/A
Equipment put up?	Yes N/A

REPORT ALL NEAR MISSES, INJURIES, AND INCIDENTS TO YOUR SUPERVISOR