Fillable Floor Striper (Southern Utah University)

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Floor Striper (Southern Utah University)

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The Floor Striper (Southern Utah University) form is 3 pages long and contains:

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  • 2 check-boxes
  • 52 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Southern Utah University

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JOB/TASK NAME:
PAGE
OF
DATE:
EMPLOYEE(S)/POSITION(S) PERFORMING THE JOB:
SUPERVISOR(S):
ANALYSIS BY:
PLANT/LOCATION:
DEPARTMENT(S):
SHIFT
(if applicable)
:
APPROVED BY:
PERSONAL PROTECTIVE EQUIPMENT:
TRAINING REQUIREMENTS:
JOB STEPS POTENTIAL HAZARDS ACTION/PROCEDURE TO CONTROL OR ELIMINATE
1
2
3
Job Safety Analysis Form
New
Revised
1
1
February 27, 2017
N/A
Custodial Department
Southern Utah University
FM: Custodial
N/A
Closed toe shoes, Gloves, Eye Protection, Proper Clothing
Equipment Training, Online CANVAS PPE Training
Check the Hazardous Materials
Surveys (Link access below)
Asbestos
Dilute chemical to suggested ratio on
bottle
Splashes
Improper dilution
Fumes
Personal Protective Equipment
Anti-slip Shoe covers if necessary
Use a Measuring cup to ensure proper dilution
Gather Equipment
Clean and Prep Area
Lifting
Slipping
Barricade the area
Proper lifting techniques
Check equipment
4
Apply Stripper
Slip, Trip, Fall
Splashes
Fumes
Water barrier
Personal Protective Equipment
Proper Ventilation
5
Mechanical Agitation and extraction
Slip, Trip, Fall
Splashes
Fumes
Personal Protective Equipment
Water barrier
Mechanical Equipment Training
Proper Ventilation
✔
6
7
Rinse and Neutralize
Restore Area and Clean-up
Personal Protective Equipment
Water barrier
Mechanical Equipment Training
Proper Ventilation
Slip, Trip, Fall
Splashes
Fumes
0
JOB/TASK NAME:
Job Safety Analysis Form
Fill in the name of the job or task being analyzed
PAGE
OF
Indicate what page of the
form this is
DATE:
Fill in the date
here
∆
NEW
∆
REVISED
EMPLOYEE(S)/POSITION(S) PERFORMING THE JOB:
Fill in the applicable name(s)/position(s) performing the job
SUPERVISOR(S):
Put the names of the supervisor
on the job
ANALYSIS BY:
Indicate name of person/group
performing the JSA
PLANT/LOCATION:
Indicate the name and location
DEPARTMENT(S):
Indicate name of department(s) in which job is
performed
SHIFT
(if applicable)
:
Fill in the shift the job is
performed on, if applicable
APPROVED BY:
Indicate the name of person who
approves JSA
PERSONAL PROTECTIVE EQUIPMENT:
Indicate PPE required to be used when performing this job
TRAINING REQUIREMENTS:
Indicate what safety trainings need to be completed before performing this job
JOB STEPS POTENTIAL HAZARDS ACTION/PROCEDURE TO CONTROL OR ELIMINATE
1
2
Fill in the job step
Fill in potential hazards associated with this step
Fill in any actions or procedures that can be used to
control or eliminate this hazard
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Floor Striper (Southern Utah University)

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Completed 25 July 2020

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