JSA Template

• Conducted on

  Date
• Location
  Address

• Prepared by

Job Task Being Assessed

• Job description

• List employees being observed during JSA

Tasks, Hazards and Preventive Measures

• Sequence of Works

• Hazard/Risk

  Select Earthmoving Truck Loading and Unloading Weather Event Working Outside Dust/Airborne Matter Fatigue Fuel Spill Noise Contact with moving object Slips Trips Physical Injury Toxic Substances Working around Underground Services Electricity Fire/Explosion

  • Earthmoving
  • Truck Loading and Unloading
  • Weather Event
  • Working Outside
  • Dust/Airborne Matter
  • Fatigue
  • Fuel Spill
  • Noise
  • Contact with moving object
  • Slips Trips
  • Physical Injury
  • Toxic Substances
  • Working around Underground Services
  • Electricity
  • Fire/Explosion
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)

  Select Chemical (Toxic, Flammable, Corrosive) Explosion (Chemical Reaction, Over Pressurization) Electrical (Shock, Short Circuit, Fire, Static, Loss of Power) Ergonomics (Strain, Sprains, Human Error) Excavation (Collapse) Fall (Slip, Trip) Fire Mechanical (Mechanical Failure, Stuck between objects) Noise Radiation (Alpha, Beta, Gamma, X-rays) Struck by Objects Extreme Temperature Visibility (lack of lighting, Obstructed vision) Weather Other

  • Chemical (Toxic, Flammable, Corrosive)
  • Explosion (Chemical Reaction, Over Pressurization)
  • Electrical (Shock, Short Circuit, Fire, Static, Loss of Power)
  • Ergonomics (Strain, Sprains, Human Error)
  • Excavation (Collapse)
  • Fall (Slip, Trip)
  • Fire
  • Mechanical (Mechanical Failure, Stuck between objects)
  • Noise
  • Radiation (Alpha, Beta, Gamma, X-rays)
  • Struck by Objects
  • Extreme Temperature
  • Visibility (lack of lighting, Obstructed vision)
  • Weather
  • Other

• Enter other potential risk/s identified

• Rate risk/ hazard before control measures

  Extremely High Risk

  High Risk

  Moderate Risk

  Low Risk

• Take a photo of step/ activity (Optional)

  Media

• Hazard Control Measures

• Explanation of control measures

Environmental

• Environmental Impact

• Barricade or signage

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• PPE Requirments

  Select

Recommendation from Health and Safety Committee

• Recommendations

Completion

• Full Name and Signature of Inspector

  Sign

• Full Name and Signature of Health and Safety Committee Member

  Sign