CLS Job Safety Analysis Report – Collins Land Services, LLC

To be completed each Monday morning, when moving to a new project, or when the scope of work changes in the project you are currently on.

Name of Person Completing Report(Required)

Date(Required)

Report Type(Required)

New Report

Revised Report

Job Site Name(Required)

Include Contract Number and type of work performed (i.e: E3Z06 Jackson Washington Outfall Ditch Maintenance)

Weather Conditions(Required)

Indicate weather conditions observed at time of reporting

Ground Conditions(Required)

Indicate ground conditions observed at time of reporting

In case of incident/emergency, contact the following people:

Name(Required)

First Last

Phone(Required)

Company Represented:(Required)

i.e.: Collins Land Services, FDOT, KCA, etc.

Name

First Last

Phone

Company Represented:

i.e.: Collins Land Services, FDOT, KCA, etc.

Name

First Last

Phone

Company Represented:

i.e.: Collins Land Services, FDOT, KCA, etc.

Key Project Pay Items

List the core job responsibilities within this project and identify the Potential Hazards and Recommended Actions for each pay item

Pay Item Name(Required)

i.e.: fence installation, ditch clearing, pond mowing, pipe laying, utility work, etc

Potential Hazards(Required)

(Energy Sources & Dangers, Potential Exposure to Hazards)

RECOMMENDED ACTION(S)(Required)

What can be done to minimize danger?

Pay Item Name(Required)

i.e.: fence installation, ditch clearing, pond mowing, pipe laying, utility work, etc

Potential Hazards(Required)

(Energy Sources & Dangers, Potential Exposure to Hazards)

RECOMMENDED ACTION(S)(Required)

What can be done to minimize danger?

Pay Item Name(Required)

i.e.: fence installation, ditch clearing, pond mowing, pipe laying, utility work, etc

Potential Hazards(Required)

(Energy Sources & Dangers, Potential Exposure to Hazards)

RECOMMENDED ACTION(S)(Required)

What can be done to minimize danger?

Pay Item Name

i.e.: fence installation, ditch clearing, pond mowing, pipe laying, utility work, etc

Potential Hazards

(Energy Sources & Dangers, Potential Exposure to Hazards)

RECOMMENDED ACTION(S)

What can be done to minimize danger?

Pay Item Name

i.e.: fence installation, ditch clearing, pond mowing, pipe laying, utility work, etc

Potential Hazards

(Energy Sources & Dangers, Potential Exposure to Hazards)

RECOMMENDED ACTION(S)

What can be done to minimize danger?

Pay Item Name

i.e.: fence installation, ditch clearing, pond mowing, pipe laying, utility work, etc

Potential Hazards

(Energy Sources & Dangers, Potential Exposure to Hazards)

RECOMMENDED ACTION(S)

What can be done to minimize danger?

Pay Item Name

i.e.: fence installation, ditch clearing, pond mowing, pipe laying, utility work, etc

Potential Hazards

(Energy Sources & Dangers, Potential Exposure to Hazards)

RECOMMENDED ACTION(S)

What can be done to minimize danger?

Pay Item Name

i.e.: fence installation, ditch clearing, pond mowing, pipe laying, utility work, etc

Potential Hazards

(Energy Sources & Dangers, Potential Exposure to Hazards)

RECOMMENDED ACTION(S)

What can be done to minimize danger?

Stop Work Authority

Stop Work Authority Triggers(Required)

What conditions, job changes, or distractions will trigger the use of Stop Work Authority on the Job?

JSA Meeting Participants

List all CLS staff participating in meeting. Signatures from each are required, and will be compared with time card data to verify.

Participant(Required)

Signature(Required)

Participant

Signature

Participant

Signature

Participant

Signature

Participant

Signature

Participant

Signature

Participant

Signature

Participant

Signature

Participant

Signature

Participant

Signature