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

• 1) Break a job down into smaller tasks and observe a worker performing it
  2) Click + to add a "Job Step" and fill in the relevant information
  3) Identify the potential hazards for each task
  4) Determine preventive measures and controls to overcome these hazards

Job Step

• Enter job step description

• 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 Pinch Points 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
  • Pinch Points
  • 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

  Select Engineering Controls Administrative Controls Personal Protective Equipment Other

  • Engineering Controls
  • Administrative Controls
  • Personal Protective Equipment
  • Other

• Engineering Controls

• Administrative Controls

• Personal Protective Equipment

• Other preventive measures

• Explanation of control measures

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