Comprehensive Job Hazard Analysis Form

• Client / Site

• Job Number

• JSA Number

• Date

  Date
• Location
  Address

JSA Details

• Individuals involved with the development of the JSA
  
  Click "Add Personnel" to enlist names & roles

Personnel

• • Full Name & Role

Work Permits / Authorizations Required

• Select the applicable work permit(s) / authorization(s) required

  Select Working at Heights High Voltage Confined Space Notifiable Work Crane Work Hot Work Isolation (Lock out) Hazardous Work Excavation & Trenching Traffic Management Plan Other

  • Working at Heights
  • High Voltage
  • Confined Space
  • Notifiable Work
  • Crane Work
  • Hot Work
  • Isolation (Lock out)
  • Hazardous Work
  • Excavation & Trenching
  • Traffic Management Plan
  • Other

• Enter other work permit

Safety Equipment Required

• 

• Select the applicable safety equipment(s) required for the job

  Select Hi Viz / Safety Boots Hard Hat Eye Protection Hand Protection Ear Protection Face Protection Protective Clothing Dusk Mask / Respirator Gas Detector Life Jacket Tripod (Confined Spaces)

  • Hi Viz / Safety Boots
  • Hard Hat
  • Eye Protection
  • Hand Protection
  • Ear Protection
  • Face Protection
  • Protective Clothing
  • Dusk Mask / Respirator
  • Gas Detector
  • Life Jacket
  • Tripod (Confined Spaces)

Competencies & Trainings

• List down applicable competencies & training to carry out individual tasks (Enumerate)

Equipment Check & Special Considerations

• List down checked equipments & any special considerations (Enumerate)

Job Safety Analysis & Risk Assessment

• Job Step / Tasks and Risk Analysis
  
  Click "Add Job Step / Task" to enlist the job steps / tasks, hazards, controls & risk ratings

Job Step / Task

• • Step in Process / Task

• • Hazards

• People

  Select Communication Fatigue Human Error Not Authorized Not Competent Poor Decision Distractions Hazard Awareness Medication Manual Handling Pedestrians Stress

  • Communication
  • Fatigue
  • Human Error
  • Not Authorized
  • Not Competent
  • Poor Decision
  • Distractions
  • Hazard Awareness
  • Medication
  • Manual Handling
  • Pedestrians
  • Stress

• Work Environment

  Select Access / Interactions Confined Area Foreign Objects Lighting / Visibility Poor Ergonomics Sun Exposure Air Movement Energy Release Gravity Lightning Pressure (fluid / air) Vibration Body Positioning Fumes / Vapours Ground Stability Noise Sharp Objects Weather Conditions Chemicals Falling Objects Housekeeping Oils / Greases Slip / Trip / Falls Work Surface

  • Access / Interactions
  • Confined Area
  • Foreign Objects
  • Lighting / Visibility
  • Poor Ergonomics
  • Sun Exposure
  • Air Movement
  • Energy Release
  • Gravity
  • Lightning
  • Pressure (fluid / air)
  • Vibration
  • Body Positioning
  • Fumes / Vapours
  • Ground Stability
  • Noise
  • Sharp Objects
  • Weather Conditions
  • Chemicals
  • Falling Objects
  • Housekeeping
  • Oils / Greases
  • Slip / Trip / Falls
  • Work Surface

• Environmental

  Select Air Emissions Land Disturbance Spills / Chemical Waste Disposal Dust Noise Water Control / Runoff Wildlife

  • Air Emissions
  • Land Disturbance
  • Spills / Chemical
  • Waste Disposal
  • Dust
  • Noise
  • Water Control / Runoff
  • Wildlife

• Equipment / Plant / Machinery

  Select Caught Between Hydraulic Injection Moving Parts Pressure (fluid / air) Construction Isolation Object Weight Stored Energy Electricity Maintenance Poor Controls Tooling Guarding Modifications Poor Signage Traffic Interactions

  • Caught Between
  • Hydraulic Injection
  • Moving Parts
  • Pressure (fluid / air)
  • Construction
  • Isolation
  • Object Weight
  • Stored Energy
  • Electricity
  • Maintenance
  • Poor Controls
  • Tooling
  • Guarding
  • Modifications
  • Poor Signage
  • Traffic Interactions

• • Existing Controls

• • Initial Risk Analysis

• Consequence

  Rare

  Unlikely

  Possible

  Likely

  Almost Certain

• Likelihood

  Insignificant

  Minor

  Moderate

  Major

  Catastrophic

• Risk Rating

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• 

• 

• Additional Controls

• • Residual / Revised Risk Analysis

• 

• 

• 

• 

• 

• 

• Additional Controls

• • Residual / Revised Risk Analysis

• 

• 

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• 

JSA Acknowledgement & Completion

• Status of the JSA

  Complete

  Incomplete

• JSA conducted by (Name and Signature)

  Sign

• NOTE: If there are changes or if the JSA is incomplete, REVIEW the whole JSA and initiate the Task Review below.

Task Review

• Were any additional hazards identified while doing the task?

  Yes

  No

• Were hazards and controls have been added to the JSA form?

  Yes

  No

• • Has a copy been filed in the central filing system?

  Yes

  No

• • Is a Permit to Work required?

  Yes

  No

• • Does a procedure need amending as a result of this JSA?

  Yes

  No

• • Does the JSA trigger a training need?

  Yes

  No

• Reviewed by Area / Manager (Name and Signature)

  Sign

• Supervisor Authorization (Name and Signature)

  Sign

• Personnel Details
  
  Click "Add Personnel" to enlist names & signatures of those who were involved with the JSA

Personnel

• Name and Signature

  Sign