JOB SAFETY ANALYSIS DATE:

PREPARED BY: CUSTOMER NAME: JOB#

AREA/BLD: s
WORK SCOPE/DESCRIPTION:

EMERGENCY CONTACT PERSON: PROJECT CONTACT:

EMERGENCY PHONE NUMBER: PHONE NUMBER:

LIST PEOPLE INVOLVED IN PRE-JOB WALKTHROUGH:

MANDATORY SAFETY PRACTICES FOR ALL JOBS
Emergency contact information Hazard communication
Use all required PPE Daily safety meetings
Housekeeping Injury/illness recordkeeping and reporting
SPECIFIC HAZARD ANALYSIS AND SAFE WORK REQUIREMENTS
A detailed discussion of the unique hazards specifc to the work activity/location, should be included under the "safe work controls"
column of this Job safety analysis. This discussion must include identification of the work activity, the specific hazards present, and
the safe work requirements/controls (including PPE) to be used to alleviate/control the hazards.
KNOWN OR
POTENTIAL
HAZARDS EXAMPLES YES NO SAFE WORK CONTROLS

Nuisance, hazardous,
1. Dust combustible

Sky lights, hatch doors,

2. Floor Openings manholes, gaps or voids

Permit required? Egress, air

3. Confined Space quality, explosion hazards

4. Hot Work Cutting, Welding, Grinding

Work level is greater than 10

5. Roof Work feet above ground

6. Fall Hazards Working surface above 6’

7. Ladders Tie off points, restrictions

8. Scaffolding Bakers, Masonary, Tubular

Scissor, Boom etc. grounding?

Power lines? Weight capacity
9. Aerial Lifts of floor
 KNOWN OR
POTENTIAL
HAZARDS EXAMPLES YES NO SAFE WORK CONTROLS

11. Lock and Tag Individual, Group, Customer

Signage, Barricades,
12. Site/Vehicle Traffic Communication

13. Electrical Hazards De-energized or live

14. Asbestos Hazards Suspected, Confirmed

15. Lead Hazards Suspected, Confirmed

16. Hazardous Materials MSDS, PPE, Disposal

Full face/half face, cartridge

17. Respiratory Hazards type, disposable

18. Elevated Noise Earplugs, earmuffs, combo.

19. Temperature Extreme heat or cold.

Extremes Protective clothing

20. Other Contractors

Present? What type of work, vacinity

Caution tape, signage, danger

21. Signs & Barricades tape, communication tags

22. Walking/Working
Surfaces Ice, Oil, Water

Waste Water, VOC

23. Environmental Compliance
MINIMUM DRESS/PPE REQUIREMENTS:

Does further evaluation of the job steps, associated hazards, or safety measures need to be performed? Yes__
Yes, No
review
__ JSA before each cleaning

SUPERVISION________________________________ DATE_________________________________