R e d R i v e r /3 1 7 & SF D r
Permits Required
First
Shift:
Yes
Ca r l Sn e l l i n g
Job/Task Description:
No Description:
None
Confined Space
Hot Work
Critical Lift
Excavation
EMERGENCY RESPONSE
Emergency contacts
Site H&S Manager
Project Manager
Law Enforcement
Medical Responders
Fire Department
Hazardous Spill Response
Bill Thorn
Colm McPHearson
Intersection of County
Road 31 7 & Sunflower
Drive
Lay-down yard
Dozer
Dump Truck
Dump Truck
Equipment/Job location
GPS coordinates, site location or
directions for emergency response
318 -9748
785769
Ford
Ford
Operator
Ronaldo Jenks
Luis Alverado
Vlad Wosjewski
None
None
None
Check all that apply and give details as needed in the J ob Sequence / Hazards / Mitigation Section on page 2
Energy Isolation LOTO
/
Work Area Hazards
Working at Heights (contd.)
Confined space concerns
LOTO training verified
Scaffolding shift inspection complete
Moving equipment or vehicles
Walkthrough & discussion of LOTO
Area cordoned off below work
Lighting levels too high/low
Blocked in & locked out (verification)
Rescue personnel & procedures in place
Extreme heat or cold
Breaker open and locked
Other:
Hot Work / Welding
/
Severe weather (snow, ice t-storms)
Mechanical energy released
Excessive wind
Assured grounding
Fire extinguisher / equip at job location?
Wet, slippery, or muddy ground
Trapped dead legs of pressure
Fire watch
Ignition sources / static / grounding
Risk of trapped/non-isolated Energy
Combustibles / LEL below work area
Other:
Other:
Fire blanket
Driving / Motorized Equipment
/
Ground rod for welding machine
Task Hazards
Ergonomic concerns (bending, lifting, etc.)
Seat belts used at all times
Ground lead as close to weld as possible
Hot work near flammable sources
Potential for slips trips and falls
Condition of road or route
Caught between hazards
Spotter / safety watch required
Other:
Excavations/Trenching
/
Hand tool inspection
Unattended operation
Vehicle inspection
Utility locate performed
Fire hazards
Others working overhead / below
All loads secured
Lines located/ marked/drawings reviewed
Other jobs in area / area cordoned off
Other:
Confined Space concerns
Heavy Equipment / Cranes
/
Other:
Approved shoring on hand
Permit required (critical lift, etc.)
Proper sloping
Personal Protective Equipment
Area / Trench roped off (barricades)
Hard hat, safety glasses, safety-toed boots,
Current Operator certification on file
hi-visibility clothing/vest
Equipment Daily Inspections done
Face shield, goggles
Proper egress provided
Competent Person review
Hearing protection
Equipment swing radius clear
Gloves (rubber/leather/cotton)
Positioning and outrigger location addressed
Other:
Electrical Safety
/
Overhead power lines, utilities etc.
Respiratory Protection (SCBA or APR)
Eyewash Station location identified
Air horn or other communication
Grounding and Bonding required
Other:
Signal man / spotter
GFCI for electric power tools
Pinch locations
Ensure safe distance is maintained while
performing inspection of energized equipment
Emergency and Communication
No cell phones/PDAs/Pagers while driving
Soft, hard, muddy, wet, sloped ground
Other:
Emergency action plan reviewed
Area cordoned off
Other:
Other:
Co Rd 317 rough condition,
Working at Heights
/
Personnel Concerns
soft shoulders
New employees / Inexperienced workers
Workers Fit For Duty (medications, sleep,
physical limitations, distractions, etc.)
Language barriers addressed
Other:
Environmental Issues
Spill mitigation or containment
MSDS review
Other:
Stop the job any time anyone is concerned about safety. Stop the job if anyone identifies a hazard not recorded on the
JSEA. Be alert to any changes in personnel, conditions at the work site, or hazards not covered by the original JSEA. If it
is necessary STOP THE JOB, reassess the task and hazards, and amend the JSEA as needed.
Rev. 10/14/08
General Hazard
CB Caught Between
FF Falls From
HER Hazardous
Energy Release
SB Struck By
O Other (describe)
Specific Hazards
CB
Cleaning chemicals
Rolling fabric
O - ergonomic
Pulled muscles
SB
Struck by equipment
Job Tasks
Working on site
Dumping rock
SB
periodically
Housekeeping
JSEA Approval
Site HSM (or designee)
Crew Supervisor
Jobsite Supervisor/Foreman
Signature
Date
Carl Snelling
Roger Adams
Competent Person
ALL
WORKERS &
VISITORS TO
THE
JOB/TASK
LOCATION
MUST
REVIEW,
UNDERSTAND
& SIGN THIS
JSEA
Individual Name
Company
Bill Thorn
WC
Carl Snelling
WC
Carl
Roger Adams
WC
Carlos Carvurta
WC
Renaldo Jenks
WC
Luis Alverado
WC
Vlad Wosjewski
WC
Sylvia Sonnet
WC
Jon Kim
WC
Post Work Follow-up
Did everyone coming into the job location review & sign the JSEA?
Is the job location cleaned up and free of hazards?
Are tools and equipment cleaned and put away?
Has the Crew Supervisor been notified that the job is
complete?
Work Complete JSEA Post-Work Review
by:
Name:
Signature
Individual Name
Company
Signature
Snelling
Carlos Carvurta
Y
Y
Y
Y
/
/
/
/
N
N
N
N
Signature:
Y / N
Y / N
Y / N
Date
:
Stop the job any time anyone is concerned about safety. Stop the job if anyone identifies a hazard not recorded on the JSEA. Be alert to any changes in personnel,
conditions at the work site, or hazards not covered by the original JSEA. If it is necessary STOP THE JOB, re-assess the task and hazards, and amend the JSEA as
needed.