Daily JSA

Date Job Name Job # Physical Address

Longitude Latitude Supervisor
Job Site Exposures
Physical Hazards Health Hazards

Falls from elevations Electrical Heat Stress Lifting Hazards

Slips, Trips or Falls Underground Utilities High Noise (< 85 dBA) Confined Space
Vehicle Traffic Elevation / Site Terrain EME/RF Plants, Animals, & Insects
Other Crews onsite Above Ground Utilities Silica Exposure (Concrete Cutting) Excavation
Fire Hazards Heavy Equipment Cold Stress
Holes & Trenches Other Chemical Exposure

Hazard Control Measures

Personal Protective Equipment / Monitoring Weather Conditions Health Hazards

Safety Glasses Hard Hat Temperature: Hi____ Lo____ Tools / Equipment Tag Lines 4 in 1 Sign
Fall Protection Hearing Wind Speed: _____________ Housekeeping Hoists Capstan
RF Suits Gloves Rain: Yes No Gin Poles Tailgate Meeting
RF Monitors Rigging Lockout/Tagout

Job Safety | Task for

Check safety procedures / work being performed: Today
First Aid Kit on site CPR Kit on site Crew Electrical Tower Audit (Pre, Post, or COP)
Rescue Bag at Base of Tower Fire Safety Banner Civil/Concrete Tower Erection
Extinguisher (AT LEAST 5lb) Other: Line and Antennas Tower Rigged for Rescue

Complete for Tower Work (Fall Protection & Using Suspended Personnel Platform)
Type of Tower / Rooftop: Safety Climb Inspection by Competent Person:
Type of Antenna Boom:
Signature:
Fall protection to be used:
Full Body Harness Anchorage Straps Top Anchorage Inspected Yes No
Retractable Lifeline Cable Grab Bottom Anchorage Inspected Yes No
Rope Grab Descenders Cable Inspected Yes No
Double Leg or Two Lanyards Ropes Cable Tension Inspected Yes No

1. Has each employee inspected his or her fall protection equipment?

2. Describe the fall protection system to be used when accessing the antenna boom or performing tower erection:

Hoisting equipment to be used Suspended Personnel Platform (Manbasket) Crane/Boom Truck (Circle One) Aerial Lift (MEWP)
has been inspected: Over 20mph not authorized Over 20 mph not authorized over 15mph not authorized

3. Has a Suspended Platform Critical Lift Checklist been completed? Yes No

Job / Tasks Potential Hazards Preventive Measures

 Project Personnel
CPR / Certified Aerial Lift Osha 10 Osha 30 Rigging RF NWSA Certification
Name Company First Aid Climber
Yes Yes Yes Yes Yes Yes Yes Yes Number

Yes Yes Yes Yes Yes Yes Yes Yes Number

Yes Yes Yes Yes Yes Yes Yes Yes Number

Yes Yes Yes Yes Yes Yes Yes Yes Number

Yes Yes Yes Yes Yes Yes Yes Yes Number

Emergency Procedures
List telephone numbers and attach directions to the site:
Are 911 systems functional with cell phone use? Yes No
Rescue Procedures to be used:
Fire Department In-House Crew (Crew must be properly trained in rescue)
Name of Appointed Rescuer: Other:
Ambulance: Fire: Police:
Local Hospital: Telephone Co.: Utility Co.:
Evacuation Point: Nexius FSM: Velex CS:
Complete for Civil Work
1. Describe type and depth of excavations:
2. Cave-in control measures to be used if excavation will be greater than 5 feet and personnel are entering the trench:
Sloping Benching Shoring Trench Shield/Box Ladder in Trench at 4 feet

3. Describe elevation / site terrain / environmental concerns or hazards:

4. Describe hazards with site / vehicle access (i.e. boom and cranes /electrical lines) and storage of materials:
5. Describe the type of electrical concerns or hazards:
RF Mapping N/A Capstan Inspection N/A Rigging Clasification
Obtain RF reading at work elevation 0% @ Drum condition Pass Fail Rigging Plan Class I II III IV
300'
and ground work areas. Provide sketch Rope locking device Pass Fail
reference of site. Rigging Plan onsite? Yes No
0%
Safety Bar Pass Fail
0%
Control switch/Foot pedal Pass Fail
0%
Labels Pass Fail Qualified Person:
GFCI at source Pass Fail
Competent Rigger:
Anchorage Type
Swivel mount Vehicle used for hoist Rigging plan will be onsite during all rigging
Straight hitch anchorage has sufficiently operations. Rigging to any appurtenance (Handrails,
ballast weight in bed. (ex. platforms) require a class IV rigging plan.
Chain mount Carabiners SHALL not be used in any type of
Tower Leg Full Toolbox)
rigging activity.
Utility Pole Yes No

Rope Inspection Sling Inspection

Are there any tears or cuts? Yes No Are there any tears or cuts? Yes No
Are there any spots of Discoloration? Yes No Are there any spots of Discoloration? Yes No
Is there indication of serious Fraying? Yes No Is there indication of serious Fraying? Yes No
Are there depressions that would Yes No Are there depressions that would Yes No
indicate internal broken strands? indicate internal broken strands?
Are there glossy or glazing areas that Yes No Are there glossy or glazing areas that Yes No
may indicate heating? may indicate heating?

ALL PERSONNEL REVIEWS AND SIGNATURES

CM / Foreman / Tower Techs / Subcontractors
Name Signature PPE Inspected? Name Signature PPE Inspected?
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes Yes