Job Safety Analysis Worksheet

• JSA no.

• Task Indentification

• Location
  Address

• Audit Title

• Conducted on

  Date

• Prepared by

Hazard Identification

• List the steps required to perform the task in the sequence they are carried out

Step no.

• Job Step

• Potential hazard- List the potential risk/hazards that could cause injury/damage when the task step is performed

• Probability

  Common

  Known to occur

  Could Occur

  Not likely

  Practically impossible

• Consequences

• People

  Fatality or permanent disability

  Lost time injury or illness

  Medical treatment

  First aid treatment

  Incident report only

• Environment

  Toxic release off site with detrimental effect

  Off site release with no detrimental effect

  Off site release contained with outside assistance

  On site release immediately contained

  No environmental impact

• Risk rank

  High

  Significant

  Medium

  Low

• Required hazard control- List the control measures required to eliminate or minimise the risk of injury

• Image

  Media

• Corrective action

• By whom

• Risk Matrix

  

Additional Comments

• Additional comments

• Corrective action comments

I have read, understand and will adhere to the requirements of this JSA

• Name

• Employee signature

  Sign

• Date

  Date

• Name

• Employee signature

  Sign

• Date

  Date

This JSA is signed off by the:

Manager

• Name

• Signature

  Sign

• Date

  Date

Supervisor/Coordinator

• Name

• Signature

  Sign

• Date

  Date

OHSW/Risk Coordinator

• Name

• Signature

  Sign

• Date

  Date

A copy of this JSA must be forwarded to the OHSW/Risk Coordinator for OHSW audit compliance