JSA - City of Greater Geraldton - Draft V1

• Document No.

• Conducted on

  Date

• Prepared by (Enter your name here)

• Location
  Address

JOB SAFETY ANALYSIS JSAs are valid for the duration of the task/job.

• Spot the hazard
  Assess the risk
  Make the changes

• Title of TASK/JOB:

• Add location
  Address

• Job NO # and Plant ID #:

• Contractor or Department:

• Plant, Equipment & Tools:

PERSONAL PROTECTIVE CLOTHING

• PPE Requirements for the Task/Job

  Select Hard Hat Gloves Safety Glasses Foot Protection Ear Protection Hi Visibility Clothing or Vest Face / Dust Mask Respirator Protective Clothing ie. Coverall

  • Hard Hat
  • Gloves
  • Safety Glasses
  • Foot Protection
  • Ear Protection
  • Hi Visibility Clothing or Vest
  • Face / Dust Mask
  • Respirator
  • Protective Clothing ie. Coverall

SIGNATURE

• Supervisor:

• Name & Sign:

  Sign

• Site Supervisor / Leading Hand:

• Name & Sign:

  Sign

JOB SAFETY ANALYSIS

• Job Step No / Hazards / Control Measures.

• Job Step

Step

• Add Job Steps

Hazards

• Add Hazards

Control Measures

• CGG Risk Assessment Matrix

• Risk Rating

Low 1-4, Medium 5 - 9, High 10 - 16, Extreme 17 - 25

• Risk Rating

  Low 1 - 4

  Medium 5 - 9

  High 10 - 16

  Extreme 17 - 25

Team Members Name & Sign "Must read and agree to the JSA before signing onto it as it is a legal binding contract.

Team Members

• Name & Sign.

  Sign

JSA Reviewed / Changes made & Approved

• Date & Time:

  Date
Job Step

• Job Step:

Description of Change

• Change:

• New Controls:

New Controls

• New Controls:

Change Approved

• Name $ Sign:

  Sign

• Date & Time:

  Date