Job Safety Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• SITE ADDRESS:

• CONTRACTOR NAME:

• CONTRACTOR'S JOB TITLE:

• LOCATION OF JOB ON SITE:

• BRIEF JOB DESCRIPTION:

• CLIENT CONTACT NAME:

• CLIENT CONTACT JOB TITLE:

JOB TASKS

• ACTIVITY

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

• ACTIVITY

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

• ACTIVITY

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

• ACTIVITY

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

• ACTIVITY

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

• ACTIVITY

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

GENERAL - workplace inspection follow up

• Has there been any significant changes to the workplace / new hazards identified in general since the last workplace inspection was completed? <br>E.G. Poor lighting, tripping hazards in walkways, fire exit signs not working, no fire extinguishers, no drinking water available, dangerous power leads, etc.

  Yes

  No

  N/A

• If yes, please list below:

• AREA

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

• AREA

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

• AREA

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

• AREA

• HAZARDS

• RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RISK CONTROL MEASURES

• RESIDUAL RISK

  Select very low low medium high critical

  • very low
  • low
  • medium
  • high
  • critical

• RESPONSIBILITY

• NOTES

CONSULTATION ATTENDEES

ORIGINAL

• I have been consulted in regards to the above Job Safety Assessment (JSA) and am aware of any hazards identified.

• CLIENT CONTACT:

  Sign

• Select date

  Date

• FORSYTHES CONTACT:

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  Date

• CANDIDATE:

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  Date

• CANDIDATE:

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  Date

• CANDIDATE:

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• CANDIDATE:

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• CANDIDATE:

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• CANDIDATE:

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• Select date

  Date

REVIEW

• I agree that there have been no new hazards identified and the original Job Safety Assessment (JSA) applies.

• CLIENT CONTACT:

  Sign

• Select date

  Date

• FORSYTHES CONTACT:

  Sign

• Select date

  Date

• CANDIDATE:

  Sign

• Select date

  Date

• CANDIDATE:

  Sign

• Select date

  Date

• CANDIDATE:

  Sign

• Select date

  Date

• CANDIDATE:

  Sign

• Select date

  Date

• CANDIDATE:

  Sign

• Select date

  Date