Fillable Printable Job Safety Analysis Worksheet

Job Safety Analysis Worksheet

Company name:

Site name:

Contractor:

Activity:

Date: JSA No.

Permit to work requirement: Yes No

Approved by:

Activity

List the tasks required to perform the activity in the

sequence they are carried out.

Hazards

Against each task list the hazards that could cause injury

when the task is performed.

Risk control measures

List the control measures required to eliminate or minimise

the risk of injury arising from the identified hazard.

Who is responsible?

Write the name of the person responsible (supervisor or

above) to implement the control measure identified.

Remember: Each JSA must be site specific .

Include all workers in the development of this JSA.