JSA #12345123: John Doe - 05/24/2024 - Test Activity (61)

Date

JOB/ACTIVITY NAME(Required)

JSA #

DEPARTMENT/GROUP NAME(Required)

BLDG/AREA LOCATION(s)(Required)

OTHER INFORMATION

REQUIRED PERSONAL PROTECTIVE EQUIPMENT FOR ENTIRE JOB(Required)

Basic Steps(Required)

Potential Hazards(Required)

Controls(Required)

Basic Steps

Potential Hazards

Controls

Basic Steps

Potential Hazards

Controls

Basic Steps

Potential Hazards

Controls

Basic Steps

Potential Hazards

Controls

Basic Steps

Potential Hazards

Controls

Basic Steps

Potential Hazards

Controls

Basic Steps

Potential Hazards

Controls

Basic Steps

Potential Hazards

Controls

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)

Signature(Required)

Date

Worker Name(Required)

Signature(Required)

Date

Worker Name(Required)

Signature(Required)

Date

Worker Name(Required)

Signature(Required)

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(Required)

Signature(Required)

Date

Send Form to Client?(Required)

Yes

Client Name

First Last

Client Email

Enter Email Confirm Email

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