Job Safety Analysis Worksheet

• Client / Site/ Project

• Conducted on

  Date

• Prepared by

• Location
  Address

Job Information

• Select date

  Date
• Add location
  Address

• Task

Sequence of steps

• Step 1

• Hazards Associated with Step 1

• Add media

  Media

• Safe Work Procedures / PPE for Step 1

• Step 2

• Hazards Associated with Step 2

• Add media

  Media

• Safe Work Procedures / PPE for Step 2

• Step 3

• Hazards Associated with Step 3

• Add media

  Media

• Safe Work Procedures / PPE for Step 3

• Step 4

• Hazards Associated with Step 4

• Add media

  Media

• Safe Work Procedures / PPE for Step 4

• Step 5

• Hazards Associated with Step 5

• Add media

  Media

• Safe Work Procedures / PPE for Step 5

• Step 6

• Hazards Associated with Step 6

• Add media

  Media

• Safe Work Procedures / PPE for Step 6

• Step 7

• Hazards Associated with Step 7

• Add media

  Media

• Safe Work Procedures / PPE for Step 7

• Step 8

• Hazards Associated with Step 8

• Add media

  Media

• Safe Work Procedures / PPE for Step 8

Jobsite and Task Checklist

• Are permits required? (hot work, confined spaces, etc.)

  No

  Yes

  N/A

• Is special training needed? (Forklift, Scaffold, Powder Actuated Tool)

  No

  Yes

  N/A

• Can weather conditions affect safety?

  No

  Yes

  N/A

• Is lighting a problem?

  No

  Yes

  N/A

• Contact with acids, toxic or caustics? (MSDS)

  No

  Yes

  N/A

• Will there be exposure to dust, fumes or mist? (MSDS)

  No

  Yes

  N/A

• Is the employee working with sharp or rough materials that require PPE?

  No

  Yes

  N/A

• Can the worker slip, trip or fall?

  No

  Yes

  N/A

• Do tools, machines or equipment present any hazards?

  No

  Yes

  N/A

• Can any body part get caught in, struck by or caught between objects? THIS INCLUDES HANDS, THINK BEFORE YOU REACH

  No

  Yes

  N/A

• Can pushing, pulling, lifting, bending or twisting cause strain?

  No

  Yes

  N/A

• Is there danger from falling objects?

  No

  Yes

  N/A

• Is excessive noise or vibration a problem?

  No

  Yes

  N/A

• Are there flammable, explosive or electrical hazards?

  No

  Yes

  N/A

• Fall hazard from one level to another or same level?

  No

  Yes

  N/A

Signatures

• Employee 1

  Sign

• Employee 2

  Sign

• Employee 3

  Sign

• Employee 4

  Sign

• Employee 5

  Sign

• Employee 6

  Sign

• Employee 7

  Sign

• Employee 8

  Sign

• Employee 9

  Sign

• Employee 9

  Sign

• Employee 10

  Sign

• Employee 11

  Sign

• Employee 12

  Sign

Comments/Discussion

• Comments/Discussion

• Add media

  Media