Job Safety Analysis Form PDF Details

In the realm of workplace safety and operational efficiency, the Job Safety Analysis (JSA) form serves as a critical tool designed to mitigate risks and prevent incidents before they occur. By carefully documenting each task within a job, identifying potential hazards, and prescribing recommended actions or procedures to control these risks, the JSA form systematically enhances the safety of employees and the work environment. It prompts supervisors and workers to communicate effectively about the dangers associated with specific job tasks, ranging from chemical and biological hazards to physical and ergonomic risks. Moreover, the form requires a detailed inventory of necessary protective equipment, permits for safe work, conditions that might necessitate stop work authority, and methods for hazardous energy control. It even goes as far as to consider environmental factors and the need for specific tools or equipment, ensuring that all bases are covered to maintain a safe workspace. Through the structured process of examining job steps to identify hazards, the form not only prioritizes worker safety but also contributes to a culture of preventive maintenance and accident readiness. The inclusion of a work site diagram and a comprehensive review process further underscores the form’s thoroughness in planning and preparedness, making it an essential instrument for job safety analysis in various industries.

QuestionAnswer
Form NameJob Safety Analysis Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesosha job hazard analysis template, job site hazard analysis form, energiz, job hazard analysis template

Form Preview Example

 

 

In case of an incident, the following people

Job/Task: ___________________________________________________ Date: ___________

 

will be contacted:

New

Supervisor:________________________

Work Location: _____________________________________

Safety:___________________________

Revised

Employee(s): _________________________________________________________________

 

 

Other:_____________________________

What is the most hazardous part of this job and what are you going to do to control the hazard?_____________________________________

Are you properly trained to complete these tasks? _______________________________________

What do you need to ensure this job is completed incident and injury free? _____________________________________________________

What conditions, job changes or distractions could call for the need to use Stop Work Authority?_____________________________________

 

Sequence of Job Steps

 

 

 

Potential Hazard(s)

 

Recommended Action/Procedure

 

Examine each step

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

carefully to find and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

identify hazards or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

potential dangers that

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

could lead to injury,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

illness or damage.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Consider the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chemical Hazard:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Inhalation _Skin Contact

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Absorption _Injection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Ingestion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Biological Hazards:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Bloodborne Pathogens

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Mold _Valley Fever

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Plant/Insect/Animal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Hazards:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Electrical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Fire/Explosion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Noise _Radiation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Thermal Stress

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Pinch Point/Line of Fire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Slips/Falls

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Strike against/Struck by

 

Additional Personal

face shield

 

chemical goggles

chemical protective clothing rubber boots chemical resistant gloves

 

Ergonomic Hazards:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

leather gloves

cut resistant gloves

respiratory protection ______________________

arm protection

 

_Repetition

 

Protective Equipment Req’d

 

 

hearing protection

fall protection Other ____________________________________________________

 

_Forceful exertion

 

 

 

 

Required Permits/Safe Work

General SWP

Hot Work Permit

Confined Space Entry

Excavation and Trenching

Lift Plan/Crane Ops

 

_Awkward Posture

 

Plans

Work in proximity to Overhead Conductors

Simultaneous Operations

 

 

_Contact Stress

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_Vibration

 

Gas Detection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H2S monitor

LEL, O2, H2S, CO Monitor

Other _______________________________________________

 

_Work Area Design

 

Equipment Needed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List hazardous substances

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSDS reviewed? yes n/a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Site Control

barricades

post signs

caution tape

designated area for vehicles heavy equipment spotter

 

 

 

 

 

 

establish meet and greet process

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Environmental Conditions

Weather:

 

 

 

 

 

Terrain:

 

 

 

Wildlife:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hazardous Energy Control

LO/TO checklist complete

LO/TO devices in place energy isolation verified

 

 

 

 

 

 

 

electrical

hydraulic

pneumatic

mechanical thermal

chemical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tools and Equipment

pre-use inspection complete

trained in use of tool/equipment

 

 

 

 

 

 

 

List tools/equipment being used:____________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work Site Diagram – Include equipment set-up, evacuation route, assembly area and identified hazards

JSA Reviewed by:

_________________________________

_____________________________________

____________________________________

_________________________________

_____________________________________

____________________________________

_________________________________

_____________________________________

____________________________________

_________________________________

_____________________________________

____________________________________

_________________________________

_____________________________________

____________________________________

_________________________________

_____________________________________

____________________________________

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