JOB SAFETY ANALYSIS Page 1 of 3

Date: / Location:
DescribeSpecific Job Being Analyzed: / The supervisor of the job/task/activity/workonsite must conduct the JSA, sign the JSA, and ensure that all personnel participating in the job understand and sign the JSA.
JSA Conducted By:
Designated UWA:
NOTE: Fieldwood Safe Work Practices For All Activities Selected Must be Reviewed and Considered In Development of the Job Safety Analysis
All Hazards, PPE and Permits Identified Below Must Be Addressed in JSA
Hazard Checklist: / Additional PPE Checklist: / Permits /Procedures Required:
Fire/Hotwork
Open Holes
Falling Objects
SimOps
Pinch Points
Cranes/Rigging
Stored Energy
Electricity / Chemicals
Spills/Leaks
Heights
Noise
Pressure
Fumes
Vibration
Other: / Weather
Lighting
Confined Space
Moving Machinery
Insect/Animal Bites
Tools/Equipment
Rotating Equipment
Hot Surfaces / Face Shield
Goggles
Special Gloves
Hearing Protection
Personal Flotation
Fall Protection
Respirator
Other: / Hot Work Permit
Confined Space Entry Permit
Energy Isolation/LOTO Permit
Open Process Piping Permit
Crane Operation and Rigging
Fall Protection Procedures
Open Hole Barricade
Others:

List All Personnel Involved With Job Including Supervisor (Please Print Name & Initial):

Print Name

/

Initials

/

Company

/

Print Name

/

Initials

/

Company

SEQUENCE OF JOB STEPS

/

POTENTIAL SAFETY OR ENVIRONMENTAL HAZARDS FOR EACH STEP

/

SAFETY OR ENVIRONMENTAL HAZARD CONTROLS

FOR EACH STEP

/

RESPONSIBLE PERSON(S)

(IF APPLICABLE)
***EVERYONE HAS STOP WORK AUTHORITY***
If Stop Work is initiated,the person with UWA must be notified and must authorize return to work.

(Note: Use another form and number accordingly if additional space is needed for names or job sequence steps)

Signatures:(indicate individuals are aware of the hazards andwill adhere to the recommended preventions and mitigations while performing and/or supervising the job)

Supervisor of Job/Task/Activity/Work:Name (print): Company:

Signature:Date:

Person in Charge or Consultant: Name (print): Company:

Signature: Date:

Authorization to Resume Work

When Stop Work Authority (SWA) is initiated, the individual with Ultimate Work
Authority is responsible for documenting, as soon as practical, that the risk,
hazard or danger no longer exists, and it is safe to resume work.
Description of Stop Work and Corrective Actions:
Ultimate Work Authority (UWA) Approval to Resume Work Signature: / Time: / Date: