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Site Safety and Health Plan <br /> Job Safety Analysis Field Sheet Check List <br /> Date: Job No. Permit No. <br /> Work Type: ❑New ❑Revised <br /> Work Site(Project Location): <br /> Organization: <br /> Consider the following,check the items that apply to the job,and then review with the work crew: <br /> Permits Welding Hazards(Environmental) <br /> ❑ Required ❑ Flashburns ❑ Electrical Shock <br /> ❑ Cold Work ❑ Combustibles ❑ Heat Stress <br /> ❑ Hot Work ❑ Spark Containment ❑ Heavy Objects <br /> ❑ Entry Permit ❑ Shields ❑ Hot/Cold Surf.or Mat. <br /> ❑ All Conditions Met ❑ Grounding ❑ Inadequate Lighting <br /> Signed Off When Complete ❑ Water Hose ❑ Line Breaking <br /> ❑ Otber: ❑ Fire Extinguisher ❑ Noise <br /> Personal Protective Equip.(PPE) ❑ Fire Blanket ❑ Poor Access/E ress <br /> ❑ Types of Gloves ❑ Fire Watch ❑ SharpObjects <br /> ❑ Composition of Gloves: ❑ Sewer Covers ❑ Other: <br /> ❑ Other: Hazards/Chemicals <br /> ❑ Special Purpose Gloves Overhead Work ❑ Chemical Burn Shin/Eyes <br /> ❑ Tyvek Suit ❑ Barricades ❑ Flammable <br /> ❑ Acid Suit/Slicker Suit ❑ Signs ❑ Ingestion <br /> ❑ Rubber Boots ❑ Hole Cover ❑ Inhalation <br /> ❑ Mono Goggles vented/non- ❑ Handrail ❑ Skin contamination <br /> ❑ Face Shield ❑ Other: Hazards/Body <br /> ❑ Respirator Electrical ❑ Fall Potential <br /> ❑ Fresh Air ❑ Locked&Tagged Out ❑ Pinch Points <br /> ❑ Ear Protection ❑ Try Start/Stop Switch ❑ Slip-Trip Potential <br /> ❑ Safety Harness ❑ GFCI Test ❑ Other: <br /> ❑ Burning Goggles ❑ Assured Grounding Other Work in Area <br /> ❑ Other: ❑ Extension Cord Ins ection ❑ Others Working Overhead <br /> Tools ❑ Other: ❑ Type Work Others Doing <br /> ❑ Current Inspection Lifting ❑ PPE Due to Other Work <br /> ❑ Proper Tools for the Job ❑ Forklift ❑ Other: <br /> ❑ Good Tool Condition ❑ Cherry Picker Access <br /> ❑ Qualifications ❑ Load Chart ❑ Scaffold(Properly Inspected) <br /> ❑ Other: ❑ Angle ❑ Ladder(Tied Of <br /> EmerlZency Equipment ❑ Crane ❑ Manlift <br /> ❑ Fire Extinguishers ❑ Proper Rigging Practices ❑ Personnel Basket <br /> ❑ Safety Shower ❑ Manual Lifting (Inspected&Approved) <br /> ❑ Evacuation Route ❑ Condition of Equipment ❑ O erator Training <br /> ❑ Other: ❑ Operation Certificate ❑ S ecial Provisions <br /> ❑ Other: <br /> Confined Space Know the following:) <br /> Possible hazards within the confined First signs of exposure. How to summons help. <br /> space. <br /> How to track personnel. Entering and exiting the confined space. Maintain contact with all entrants by <br /> voice or visual. <br /> Do not attempt to rescue unless you are Remain at entry point;assume no duties <br /> a part of a coordinated effort. will take you from there. <br /> JSA Form originated by: <br /> Supervisor/Foreman: <br /> Recommendations: <br /> Incident Free Operation Page 36 of 68 <br />