JSA

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Task

• Position/Occupation

• Company

• Location

• Supervisor Name and Title

• Worker(s) Name and Title

• Frequency Rating (3-Daily/Frequently, 2-Monthly/Occasionally, 1-Quarterly/Rarely)
  
  Severity Rating (3-Fatality/Catastrophic Property Damage, 2-Lost Time Injury/Major Property Damage, 1-Medical Aid/Minor Property Damage)
  
  Probability Rating (3-Reasonably Probable, 2-Remote, 1-Extremely Remote)

• Task Analysed

Task

Task Analysis

• Task Steps-Activities

• Photo Support

  Media

• Existing or Potential Hazards

• Health and/or Safety

  Select Health Safety

  • Health
  • Safety

• Frequency

  1

  2

  3

• Severity

  1

  2

  3

• Probability

  1

  2

  3

• Priority Rating

• Current Hazard Control

• Hazard Control Required or Improvement Recommended

• Department Involved in Implementation

  Engineering

  Administration

  PPE

• Assigned to