Title Page

  • Date:

  • Job Description:

  • Job No:

  • Division:

  • Customer/Client/Contract:

  • Location

Site Supervisor

    Name:
  • NAME:

EMERGENCY RESPONSE INFORMATION:

  • Supervisor

  • Branch Phone:

  • EMERGENCY SERVICES: 111

  • First Aid Kit

  • Fire Extinguisher

  • Spill Kit Location

  • Height Rescue Kit

Hazards / Risks

Permit Requirements

  • Permits Required

  • Please Specify

  • Critical Risks Activities to consider

Step 1 -Planning

  • Are there any hazard controls required with this step?

  • Identify the hazard controls

  • Initial risk assessment

  • Residual risk assessment

Step 2- Site Setup

  • Are there any hazards associated with this step?

  • Identify Hazard

  • Please specify

  • Initial risk assessment

  • Hazard control summary

  • Residual risk assessment

Step 3- During the work

  • Are there any hazards associated with this step?

  • Identify Hazards

  • Please specify

  • Initial risk assessment

  • Hazard control summary

  • Residual risk assessment

Step 4- Job completion / Quality Assurance

  • Are there any hazards associated with this step?

  • Identify Hazards

  • Please specify

  • Initial risk assessment

  • Hazard control summary

  • Residual risk assessment

Changing Conditions

  • Identify changes in the workplace

  • Please specify

  • Initial risk assessment

  • Hazard control summary

  • Residual risk assessment

Risk assessment matrix

  • Risk assessment matrix

Sign Off

Job Safety and Environmental Analysis Work Team Sign-On

  • The undersigned acknowledge that they have read and understood the safe work controls identified in the JSEA and will report any changes in site safety to the Site Supervisor .

Work Team and Visitor Sign-On

Daily Sign On / Off

    Name and Role
  • Name and Role of Team Member / Contractors/ Visitors

  • Signature

  • Sign On Date & Time

  • Sign Off Date & Time

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.