Title Page
-
Date
-
Location
-
Prepared by
-
Job Order Number
-
Customer Present :
- Yes
- No
- N/A
Untitled Page
-
The customer, and any other persons who may potentially be affected by our work, has been provided safety instructions e.g. No go areas
-
1A. Are there any additional hazards that are not included in the JSA / SWMS and need to be controlled?
-
1B. Is there an increased risk to workers due to environmental conditions? e.g. heat, rain, wind etc.
-
If above1A or 1B answer yes, please list hazards & controls in next Page
Hazards identified
- Add additional hazards identified
-
List additional hazards identified List the risk control measures
-
List the risk control measures
-
Who is responsible for the control measures being implemented
-
(If you have multiple hazards please use "+" to add a new line
Job Safety Analysis - Contents
-
Please review the Job Safety Analysis Document
-
Have you read and understand the document
Approval
-
By signing this JSA I acknowledge that I understand my OHS responsibilities and will adhere to the safe working practices listed in this JSA, SWMS (if the work involves HRCW) and the Falls emergency rescue plan
(If you have multiple persons to sign, please use "+" to add a new approver)
Sign off
-
Date and time of approval
-
Approver's signature
-
