Job Safety Analysis (JSA)

• Document No.

• ServiceM8 Job #

• Customer

• Location/Site
  Address

• Conducted on

  Date

• Prepared by

• Use below Risk Matrix

Hazards / Control Measures / Risk Assessment

• Identified Hazard (Physical, Electrical, Height, Mechanical, Chemical etc.)

• Add photo (optional)

  Media

• Initial Risk Assessment

  Low

  Medium

  High

• Steps taken to Eliminate/Minimise

• Final Risk Assessment

  Low

  Medium

  High

2.1 Declaration

• I understand the Job and my Role

• I/We have an understanding of the Job/Task(s), my Role, and have discussed these with the Site Supervisor/PCBU/Contractors/Employees to the best of my/our knowledge

• I know the site safety rules applicable to the Job/Task(s)

• I/We have an understanding of the safety rules applicable to the Job/Task(s) and have discussed these with the site Supervisor/Contractors/Employees to the best of my/our knowledge

• I have identified all required PPE for the Job/Task(s)

• I/we have an understanding of all PPE required to perform the Job/Task(s) and where necessary have discussed these with the Site Supervisor/Contractors/Employees to the best of my/our knowledge

• I have identified all my known hazards

• I/we have an understanding of all Identified Hazards and steps to Eliminated/Isolate/Minimised those Hazards to the best of my/our knowledge

3.1 Additional Employees/Contractors working under this JSA

• List of Employee/Contractors

Employee/Contractor

• Add signature

  Sign