Title Page
1.2 Hazards Identified other than recognised generic Hazards
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Document No.
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Unique ID/ Job Number
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Client
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Location/Site
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Conducted on
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Prepared by
1
1.1Company/Site specific information
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Project/Job/Task
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List of Identified Hazards
Hazard
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Identified Hazard
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Add photo (optional)
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Steps taken to Eliminate/Isolate/Minimise
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2.1 Declaration
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I understand the Job/Task
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I/We have an understanding of the Job/Task(s) and have discussed these with the Site Supervisor/Contractors/Employees to the best of my/our knowledge
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I understand my role in this Job/Task(s)
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I/We have an understanding of my/our roles in this Job/Task(s) and have discussed these with the Site Supervisor/Contractors/Employees to the best of my/our knowledge
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I know the site safety rules applicable to the Job/Task(s)
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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
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I have identified all required PPE for the Job/Task(s)
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I/we have an understanding of all PPE required to perform the Job/Task(s) and have discussed these with the Site Supervisor/Contractors/Employees to the best of my/our knowledge
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I have identified all my known hazards
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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
3.1 Additional Employees/Contractors working under this JSA
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List of Employee/Contractors
Employee/Contractor
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Add signature
