Title Page
-
Site conducted
-
Role being evaluated
-
Date
InterDesign Job Safety Analysis
JSA Details
-
Personnel
-
• Full Name & Role
Safety Equipment Required
-
-
Select the applicable safety equipment(s) required for the job
- 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)
- Fall Protection
Competencies & Trainings
-
List down applicable competencies & training to carry out individual tasks (Enumerate)
- Hazard Communication
- Material Handling
- Powered Industrial Trucks
- Accident/Near Miss
- Fall Protection
- First Aid CPR
- Spill Prevention
- Hearing Conservation
- Lock Out/Tag Out
- Confined Space
- Fire Extinguisher
- Respiratory Protection
- Ergonomics (Proper Lifting)
Equipment Check & Special Considerations
-
List down checked equipments & any special considerations (Enumerate)
- Powered Industrial Truck
- Hand Pallet Jack
- Box Cutter
- Tape Gun
- Shrink wrap Machine
Job Safety Analysis & Risk Assessment
-
Job Step / Task
-
• Step in Process / Task
-
• Hazards
-
People
- Communication
- Fatigue
- Human Error
- Not Authorized
- Not Competent
- Poor Decision
- Distractions
- Hazard Awareness
- Medication
- Manual Handling
- Pedestrians
- Stress
-
Work Environment
- 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
- Spills / Chemical
- Waste Disposal
- Dust
- Noise
-
Equipment / Plant / Machinery
- Caught Between
- Moving Parts
- Pressure (fluid / air)
- Object Weight
- Stored Energy
- Electricity
- Maintenance
- Poor Controls
- Guarding
- Modifications
- Traffic Interactions
-
• Existing Controls
-
• Initial Risk Analysis
-
Likelihood
-
Consequence
-
What is the physical demand?
- Lift over 30 pounds
- Lift over 50 pounds
- Stand 8-10 hours
- Sit most of the day
- Bend, stretch, work overhead
- Sort, stack, count or verify
- Look at computer
- Possess manual dexterity
- Repetitive lifting or motions
- Regularly push or pull
-
-
-
-
-
Additional Controls
-
-
-
-
-
-
-
Additional Controls
-
-
-
-
-
JSA Acknowledgement & Completion
-
Status of the JSA
-
JSA conducted by (Name and Signature)
-
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?
-
Were hazards and controls have been added to the JSA form?
-
• Does a procedure need amending as a result of this JSA?
-
• Does the JSA trigger a training need?
-
Supervisor Authorization (Name and Signature)
-
Personnel Details
Click "Add Personnel" to enlist names & signatures of those who were involved with the JSA
Personnel
-
Name and Signature
-
Were any additional hazards identified while doing the task?
-
What additional hazards?
-
Does a procedure need amending as a result of this JSA?
-
What procedure needs added?