Matt Richerme - 10456262 - 04/03/2026 (9109)

Are you foreman today(Required)

Yes

Date(Required)

SITE LOCATION(Required)

JSA / JOB #(Required)

JOB DESCRIPTION(Required)

BLDG/AREA LOCATION(s)(Required)

Project Manager(Required)

REQUIRED PERSONAL PROTECTIVE EQUIPMENT FOR ENTIRE JOB(Required)

Hot Work(Required)

Lift Plan(Required)

Confined Space(Required)

Basic Steps(Required)

Potential Hazards(Required)

Controls(Required)

I understand & will adhere to the steps, hazards & controls as described in this JSA. I understand that performing steps out of sequence may pose hazards that have not been evaluated, nor authorized. I will contact my supervisor prior to continuing work, if the scope of work changes or new hazards are introduced. I understand I have the authority and responsibility to stop work I believe to be unsafe.

How Many Workers on this Job?(Required)

Worker Name(Required)

Worker 1 Signature

Clear

Date

Worker Name(Required)

Worker 2 Signature

Clear

Date

Worker Name(Required)

Worker 3 Signature

Clear

Date

Worker Name(Required)

Worker 4 Signature

Clear

Date

I have reviewed the steps, hazards & controls described in this JSA with all workers listed above and authorize them to perform the work. Workers are qualified to perform this activity.

Foreman Name(Required)

Foreman Signature

Clear

Date

Send Form to Client?(Required)

Yes

Client Name

First Last

Client Email

Enter Email Confirm Email

Signature

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Date

Matt Richerme - 10456262 - 04/03/2026 (9109)

Signatures