Title Page

  • Conducted on

  • Location
  • Prepared by

Job Safety Analysis (JSA)

Job Task Being Assessed

  • Job description

  • List employees being observed during JSA

Tasks, Hazards and Preventive Measures

  • Sequence of Works

  • Hazard/Risk

  • Job Step
  • Enter job step description

  • Plant, Equipment and/or Tools

  • Potential risk or hazard identified while task is being performed (select all that apply)

  • Enter other potential risk/s identified

  • Rate risk/ hazard before control measures

  • Take a photo of step/ activity (Optional)

  • Hazard Control Measures

  • Explanation of control measures

Environmental

  • Environmental Impact

  • Barricade or signage

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  • PPE Requirments

Recommendation from Health and Safety Committee

  • Recommendations

Completion

  • Full Name and Signature of Inspector

  • Full Name and Signature of Health and Safety Committee Member

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.