General Information


Select job type

Enter job type

List employees being observed during JSA

Tasks, Hazards and Preventive Measures

Click + to add a Job Step of the task being assessed


Enter job step description

Potential risk or hazard identified while task is being performed (select all that apply)

Enter other potential risk/s identified

Rate risk/ hazard before control measures

Take a photo of step/ activity (Optional)
Hazard Control Measures

Engineering Controls

Administrative Controls

Personal Protective Equipment

Other preventive measures

Recommendation from Health and Safety Committee


Full Name and Signature of Inspector
Full Name and Signature of Health and Safety Committee Member
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.