Identify Evacuation Point: Identify Alternate Evacuation point:

MSDS (Material Safety Data Sheet) is available and reviewed (potentially harmful products or substances / chemicals): YES NO NA
Emergency Numbers:
Medical Services:
SAFETY ASSESSMENT OF THE WORK TO BE PERFORMED
TASK DESCRIPTION: (work to be performed) DATE: TIME: JSTA Supervisor – Must Complete the following Safety Analysis for the work to be performed,
keeping in mind the Wilmar Safety Rules and review with crew prior to initiating work activities.
All new or late arriving workers coming in and joining this task must also be given this JSTA and
sign off. Supervisor must ensure all personnel understand the work, the hazards and how they
must protect themselves and the safe work methods that will be used.
No. SEQUENCE OF GENERAL STEPS IDENTIFIED HAZARDS / RISKS FOR PROTECTIVE MEASURES / ACTIONS TO BE TAKEN TO
FOR THE TASK TO BE PERFORMED EACH STEP ELIMINATE, OR CONTROL THE IDENTIFIED HAZARDS

Print Name: Construction Manager in charge of the job Signature: Date:

Page 1 of 3
 Acknowledgement of the Task to be performed, the Hazards and Protective Measures
At Sign On – I understand the TASK to be performed, the steps of the task, the hazards/risks, the safety precautions, and protective measures
that must be followed, the protective equipment and permit requirements when applicable, and that I had an opportunity to ask questions or
bring up additional safety concerns and have them addressed by supervision. I further understand that working safely is a requirement and a
condition of employment.
At Sign Off – I acknowledge that the work I performed and covered by this JSTA was done safely and without injury.
No. Print Name Signature No Print Name Signature
16
1
17
2
18
3
19
4
20
5
21
6

7
22
8
23
24
9
25
10
26
11
27
12
28
13
29
14
30
15

Page 2 of 3
Hazard Identification Checklist (Below are a few typical work hazards the Supervisor should consider in their JSTA)
Check off the hazards that apply to your work and consider them in your JSTA
A. Working in Elevated Areas
1 Work point not fully enclosed with guard rail
2 No safe access to elevated work point(s)
3 Holes in floor not barricaded or covered and secured
4 Falling objects or tools
5 Workers not trained in safety harness use with two lanyards
6 No points for workers to tie off continuously with safety harness lanyards
7 Danger of moving equipment / machines (i.e. bridge cranes, conveyors)
8 Tie off points for lanyards not adequate to sustain a worker that falls
B. Material Handling
1 Sharp tools or material that can cut hands, fingers or other body parts
2 Inappropriate gloves for the work (leather, rubber, kevlar, dielectric)
3 Pinch or entrapment points – fingers, hands and other body parts
4 Material to heavy for one person
5 Mechanical means to lift material is unavailable
6 Unsafe stacking of material – falling over
7 Working in a elevated position without fall protection
C. Tools (Hand & Power)
1 Required guards not in place
2 Defective tools
3 Tool not designed for the work to be performed
4 Tool not inspected by qualified person (quarterly color code)
5 No dead mans switch (when trigger is released, the tool does not stop)
6 No tool holder for hammering stakes into ground
7 No tool holder when hammering spanners (bolt tightening)
8 Untrained personnel for the tool to be used
D. Confined Space
1 Atmosphere not tested for oxygen deficiency or harmful gases/vapors
2 Pipes not locked out/blinded or disconnected entering confined space
3 Low voltage power tools not used (12 volts)
4 Hole watch not in place or trained
5 Confined Space Permit and Hole Watch register not in place
E Hazardous Energy Control (Lock and Tag-out)
1 Exact lock-out point(s) are not properly identified by qualified individual
2 Personnel without their Personal Lock and Tag-Out on isolation point
3 The equipment not tested and tried to ensure zero energy status
4 Residual energy not grounded prior to handling elements, components
5 Pipe / valve not locked out – blinded or disconnected and valve shut off
√ F. Cranes and Rigging √
1 Rigger not qualified to perform lifting activities
2 Rigging equipment/accessories not inspected with the quarterly color code
3 Boom / load swing area not barricaded off with red tape
4 No or insufficient tag lines to control the load
5 Crane operator not qualified, licensed or certified
6 No annual crane certification and monthly inspection performed
7 Crane signal person does not have continuous eye or radio contact with operator
8 Load swung over personnel
9 Unstable ground conditions for crane set up
10 Outriggers not fully extended / insufficient outrigger pads
11 Working in close proximity of overhead power lines
12 No Lifting Permit or Rigging Study in place
13 Load exceeds crane capacity as per manufacturers load chart / ratings
G. Excavations and Trenching
1 Excavation permit not available
2 No or insufficient barricading around excavation / trench
3 No or Insufficient access and egress provided
4 Area not barricaded before hole is opened
5 Excavation / trench not benched, sloped or shored as required
6 Underground utilities survey not done
7 Equipment working on the edge of excavation where personnel are working
8 Access / egress ladders not secured
H. Ladders
1 Ladders not tied off
2 Ladders not inspected and color coded
3 Employee carry in hands, tools or equipment while going up or down on ladder
4 Metal ladders used during electrical welding or near electrical lines or services
5 Ladder not held in place by a co-worker as worker goes up ladder to tie off ladder
6 Damaged ladders not tagged out
7 Ladder not extending at least 90cm beyond supporting object
I. Scaffolding
1 Incompetent scaffold erectors, erecting scaffold
2 Scaffold not inspected prior to use by a competent scaffold inspector
3 No scaffold tags / scaffold wrongly tagged
4 Scaffold modifications done by incompetent personnel
5 No safe access provided
6 Scaffold not complete or level and plumb, no base plates under scaffold jacks
Page 3 of 3