SMI JOB SAFETY ANALYSIS

• Document No.

• Job Name

• Job No.

• Conducted on

  Date

• Prepared by

GENERAL INFORMATION

• DATE

  Date

• JOB No.

• LOCATION
  Address

TASK PLAN

• WHAT TASK IS BEING PERFORMED TODAY?

• WHAT ARE THE POTENTIAL HAZARDS IN PERFORMING THE WORK?

• WHO WILL BE PERFORMING THE TASK? LIST NAMES.

• WHAT TOOLS/PROCEDURES ARE REQUIRED? PLEASE EXPLAIN

• HAVE EMPLOYEE(S) BEEN PROPERLY TRAINED TO COMPLETE TASK?

  YES

  NO

  N/A

CERTIFY

• FOREMAN SIGNATURE

  Sign