Building site: Date: Hour: Process:

Location: Supervisor work: Company:

YES/NO/N.A YES/NO/N.A
CONFINED WORK LOAD LIFTING
HEAT WORK ENERGY LOCK OTHERS
1. Prepare the surrounding
area
1.1.1.Fall at the same or different level.
1.1.2. Cuts and blows in general.
1.1.Obstacles
1.2. Sharp objects surrounding the area or on top
of the desired gathering spot.
3.1.1. Fall from different level.
3.2.1. Hits, cuts and blows (essentially to the limbs).
HEIGHT WORK
4.1.1. Cuts, blows and hits.
4.2.1. Damage to ears.
4.3.1. Eye damage, as well as lung and throat
damage.
4.4.1. Hits and cuts.
2.1.1. Cuts and blows. 2.1 The hand tools themselves.
4.1.1.1. Use a class A safety hat, safety boots and leather gloves.
4.2.1.1. Wear earplugs or noise cancelling headphones.
4.3.1.1. Wear goggles and a face mask (a filter may be optional).
4.4.1.1. Wear a class A safety hat.
CONTROL MEASURES STEPS OF WORK RISKS HAZARDS
1.1.1.1. An established and properly signalized path.
1.1.1.2. Wear the proper PPE (class A safety hat, leather gloves, safety boots and overall).
4.1. Hand tools
4.2. The sound while hammering to close the
metallic form.
4.3. Concrete particles and dust
4.4. Objects above ditch
3. Enter the working area
4. Remove the form
2. Transport the hand tools
3.1. Work at height
3.2. The entrance (sharp edges) and the
workplaces walls (protruding objects of the metallic
form).
2.1.1.1. An small talk about the risks involved
2.1.1.2. Wear cotton or leather gloves.
3.1.1.1.Wear a harness with lifeline.
3.1.1.2. A supervisor to train the worker, if the work space is too reduced.
3.2.1.1.Wear leather gloves, overall, safety boots, class A safety hat, and goggles.
WORK SHEET
RISKS CONTROL MEASURES
Is there any existance of risk of falling some
material from uppers levels ?
Does exist chemical, explosive or flammable
substances in the work place can affect to people
or the environment
The routes of entry, promotion, traffic, escape and
or stairs for the personal are adequate?
Others risks?
RISKS
Does the personal can do contact with sources of
energy electric, mechanic, hydraulic, etc?
The hand tools of power and/or machines to be use
are in good conditions?
It required signalling /perimeter railings in the work
place to prevent entry or fall of people?
Does the personal have any experience about the
work?
REQUIRED WORK PERMITS
EXCAVATIONS & DITCHS
CONTROL MEASURES
JOB SECURITY ANALYSIS
EVALUATION, CONTROL & PERMITS REQUIRED
JOB DATA
REMOVAL OF A METALLIC FORM IN CONFINED SPACES
DATE & HOUR:
COMPLETE NAME : COMPLETE NAME :
SUPERVISOR WORK : PRODUCTION ENGINEER:
Cancellation
of AST
Reason:
AUTHORIZATION & CLOSURE
SIGNATURE: Leader signature of team work
in conformity of closing JSA
COMPLETE NAME & WORK POSITION SIGNATURE :
HOUR:
SIGNATURE : SIGNATURE : SIGNATURE :
SUPERVISOR WORK:
COMPLETE NAME :
5. 10.
4. 9.
8.
2.
3.
7.
1.
COMPLETE NAME DNI SIGN COMPLETE NAME DNI SIGN
6.
WORK PERSONAL
5.1.1. A collision of the falling object into the ditch
worker head.
5.2.1. Falls at same or different level.
5.3.1. Hits to others
5.3.2. Muscular damage.
5.1.1.1. A correct use of a safety helmet (Type A)
5.1.1.2. Cleaning up the work area can reduce the hazard of obstacles
5.2.1.1. Defining a safety route
5.3.1.1. Move the large form panels by 2 workers
5.3.2.1. Use back supports.
6.1.1.1. Wear a harness with lifeline.
6.1.1.2. A supervisor to train the worker, if the work space is too reduced.
6.2.1.1.Wear leather gloves, overall, safety boots, class A safety hat, and goggles.
6. Exit the work area
6.1. Work at height
6.2. The exit (sharp edges) and the workplaces
walls (protruding objects of the metallic form). 6.1.
Same as 3.1
6.1.1. Fall from different level.
6.2.1. Hits, cuts and blows (essentially to the limbs).
5.1. The ditch is considered a dangerous task.
5.2. Obstacles surrounding the workspace.
5.3. Overweight and size of the forms.
5. Transport the form