Title Page

  • Client

  • Job Number

  • Job Description

  • Person In Charge

  • Date

  • JSA conducted by

  • Site Address
  • Instructions

    1. Choose the best response for each of the items and fill out the blank spaces provided.
    2. Add photos and notes by clicking on the paperclip icon
    3. To add corrective actions, click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority and due date
    4. Complete the audit by providing digital signature
    5. Share your report by exporting as PDF, Word, Excel or Web Link

General JSA Details

  • Is a permit to work required?

  • Can the job proceed?

Safety Equipment

  • Choose the applicable safety equiipment required

  • • Notes

Equipment Check

  • Choose all the AVAILABLE and IN WORKING CONDITION equipment

  • • Notes

  • Choose all the UNAVAILABLE and NON-WORKING CONDITION equipment

  • • Notes

Licenses / Qualifications / Training


  • • Specify

  • • Notes

Additional Checks

  • Choose the APPLICABLE CHECKS that are relevant

  • • Specify

  • • Notes

  • A. Job Tasks

  • B. Identifiable Hazards

  • • Area Hazards

  • • Height Hazards

  • • Mechanical Hazards

  • • Environmental Hazards

  • • Process Hazards

  • • Hazardous Substance

  • • Fibres Dusts Hazards

  • • Biological Hazards

  • • Specify

  • • Other Hazards

  • • Specify

  • C. Initial Risk Level

  • D. Control Measures

  • E. Residual Risk Level

Other Notes

  • Provide relevant notes on this current job safety analysis

Worker Sign-Off & Completion

  • I, the undersigned, acknowledge, that I have been consulted regarding the content of the JOB SAFETY ANALYSIS & HAZARD / RISK ASSESSMENT and the relevant hazards, control measures, rules and requirements have been explained to me and are clearly understood by me.

  • Name and Signature

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.