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Site Safety and Health Plan <br /> Job Safety Analysis Field Sheet <br /> Date: Job No. Permit No. <br /> Work Type: ❑New ❑Revised <br /> Work Site(Project Location): <br /> Organization: <br /> Personal Protective Equipment PPE),Level <br /> Hard Hat ❑ Yes ❑ No Safey AccesslLocation <br /> Steel-toed Boots ❑ Yes ❑ No Safe Haven: <br /> Hearing Protection—specific to task ❑ Yes ❑ No Wind Direction: <br /> High Visibility Traffic Safety Vest ❑ Yes ❑ No Evacuation Route: <br /> Protective Gloves—Leather work gloves El Yes ❑ No <br /> Safety Glasses&Screen Face Shield ❑ 'Yes ❑ No Assembly Point: <br /> Other: <br /> Job Steps(What are Potential Hazard(s) Critical Action(s) <br /> you doing?) <br /> EXAMPLE: Slips,Trips,Falls Clear walkways of equipment,vegetation,excavated material,tools, <br /> Backfilling and debris.Marls,identify or barricade other obstructions. <br /> Audit the Job Supervisor's Comments and Initials: <br /> Audit Time: <br /> Audit the Job Supervisor's Comments and Initials: <br /> Audit Time: <br /> Audit the Job Supervisor's Comments and Initials: <br /> Audit Time: <br /> Audit the Job Supervisor's Comments and Initials: <br /> Audit Time: <br /> JSA Form originated b <br /> Crew Name Signatures: <br /> Supervisor: <br /> Incident Free Operation Page 35 of 68 <br />