Loading...

Job Safety Analysis Form

Scope of Work: Power Washer

Location: PayPal Park

JSA Reference Number:

Date Revised: 2/14/23



Step: Pre-plan the work

Hazard: Improper tools

Improper/No Equipment Inspection.

Improper PPE inspection/selection.

Control: Using improper tools or parts can lead to ergonomic issues that can lead to injury.

Improper/Lack of Inspection can lead to injury from faulty or old parts; proper inspection can lead to repair and replacement of dangerous equipment.

Improper PPE use and inspection can lead to unnecessary hazards created by wrong PPE or faulty PPE.

Tag out broken down/dangerous equipment so no one else uses it.

Step: Before the job

Hazard: Improper Donning.

Skin or Eye Contact with fuel.

Fire.

Control: Improperly donning or not donning PPE can lead to an unnecessary exposure. Ensure all PPE is on correctly and passed inspection.

Wear appropriate PPE for any refueling or oiling; store fuel in a safe location.

Do not add fuel to a hot engine and only fuel in appropriate locations.

Step: Using the Pressure Washer

Hazard: Hand/Foot Injury Skin Intrusion/Laceration Eye Injury Burns Electrocution.

Control: Marking off the area or having a spotter will keep pedestrians away from the work area.

Wear safety toe shoes and wear gloves. Keep hands away from the tip of the wand.

Keep PPE on during entirety of work.

Avoid contact with hot parts of engine.

During preplanning of work check the site for any electrical hazards



First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!