7/23/2019 Wpc Form Jsa

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ENVIRONMENT, SAFETY & HEALTH DIVISION

Chapter 2: Work Planning and Control

Job Safety Analysis FormProduct ID: 513| Revision ID: 1262 | Date Published: 40529 | Date Eective: 40529

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SLAC National Accelerator Laboratory | n!iron"ent# Safety $ %ealt& 'i!i(ion C&a)ter 2 | Job Safety Analy(i( *or"

WorkerI +n,er(tan, an, ill a,&ere to t&e (te)(# &a.ar,(# an, control( in t&i( JSA/ I +n,er(tan, t&at )erfor"in (te)( o+t of (e+ence "ay )o(e &a.ar,( t&at &a!e not been

e!al+ate, nor a+t&ori.e,/ I ill contact t&e )er(on &o a+t&ori.e, "y or )rior to contin+in# if t&e (co)e of or c&ane( or ne &a.ar,( are intro,+ce,/ I +n,er(tan, "y (to)

or a+t&ority an, re()on(ibility/

/a)e #rint ,i'nature Date

Authorizer (administrative or functional supervisor, foreman, POC)I &a!e re!iee, t&e (te)(# &a.ar,( an, control( ,e(cribe, in t&i( JSA it& all orer( li(te, abo!e an,

a+t&ori.e t&e" to )erfor" t&e or/ orer( are +alifie, t&at i(# licen(e, or certifie,# a( a))ro)riate# an, in f+ll co")liance it& SLAC trainin re+ire"ent( to )erfor" t&i(

acti!ity/

/a)e #rint ,i'nature Date

Area or Building Manager Re, or6 if ye(# ,oc+"ent relea(e !ia I an, tailate "eetin ot&eri(e I &a!e co""+nicate, +ni+e area &a.ar,(# bo+n,ary con,ition(#

an, (o on it& t&e a+t&ori.er or li(te, orer( an, &a!e coor,inate, t&i( 8ob it& affecte, occ+)ant(/ Li(te, orer( are relea(e, to )erfor" ,e(cribe, (co)e of or/ Li(tbo+n,ary con,ition(# note(# etc/

Li(t bo+n,ary con,ition(# note(# etc

/a)e #rint ,i'nature Date

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