JOB SAFETY ANALYSIS WORKSHEET

JOB DESCRIPTION:
DATE: JSA NO.: ________
JOB SAFETY ANALYSIS

NEW REVISED Job location (Plant):
JOB LOCATION (Plant): AREA:
BASIC STEP POTENTIAL HAZARDS RECOMMENDATIONS RESPONSIBILITY STATUS











REQUIRED AND/OR RECOMMENDED P.P.E.:____________________________________________________________________

______________________________________________________________________________________________________
All recommendations suggested in JSA have been implemented at site:(Maintenance Supervisor)
Prepared by: JSA Team Leader
Acknowledged by: Operation/Shift Supervisor
Name:__________________ Signature:________ Badge #: _______

JSA Team Members
Name ID # Department Signature Date



Name:______________ Signature:__________ Badge#: __________

Reviewed and acknowledged by Operation Manager In case of
Medium / High Risk (Critical Activity).

Name:______________ Signature:__________ Badge#: __________

Comment:
..
..
..
..



Approved by Maintenance Superintendent
Name:_____________________ Signature:__________ Badge #:________
Approved by Maintenance Manager in case of Medium / High Risk
(Critical Activity).

Name:_____________________ Signature:__________ Badge #:________






INSTRUCTIONS FOR COMPLETING THE JOB SAFETY ANALYSIS FORM

Job Safety Analysis (JSA) is an important incident prevention tool that works by
finding hazards and eliminating or minimizing them before the job is preformed,
and before they have a chance to become accidents. Use JSA for job clarification
and hazard awareness, as a guide in new employees training, for periodic contacts
and for retraining of senior employees, as a refresher on jobs which run
infrequently, as an incident investigation tool, and for informing an employees of
specific job hazards and protective measures.

Set priorities for doing JSAs: jobs that have a history or many accidents, jobs that
have produced disabling injuries, jobs with high potential for disabling injury of
death, and new jobs with no accident history.

Select a job to be analyzed. Before filling out this from, consider the following:
The purpose of the job-What has to be done? Who has to do it?. The activities involved:
How is it done? When is it done? Where is it done?

In summary, to complete this form you should consider the purpose of the job, the activities
it involves, and the hazards its presents. If you are not familiar with a particular job or
operation, interview an employee who is. In addition, observing an employee performing
the job, or walking through the operation step may give additional insight into potential
hazards. You may also videotape the job and analyze it. Heres how to do each of the three
parts of Job Safety Analysis
SEQUENCE OF BASIC JOB STEPS POTENTIAL HAZARDS RECOMMENDED ACTION OR PROCEDURE
RESPONSIBLE
PERSON

Examining a specific job by breaking it
down into a series of steps of tasks, will
enable you to discover potential hazards
employees may encounter.

Each job operation will consists of a set of
steps or tasks.

For example:

The job might be to move a box from
conveyor in the receiving area to a shelf in
the storage area. To determine where a
steps begins or ends, look for a change of
activity, change in direction or movement.

Picking up the box from the conveyor and
placing it on a hand truck is one step. The
next step might be to push the loaded
hand truck to the storage area (a change
in activity). Moving the boxes from the
truck and placing them on the shelf is
another step. The final step might be
returning the hand truck to the receiving
area.

Be sure to list all the steps needed to
perform the job. Some steps may not be
performed each time; an example could be
checking the casters on the hand truck.
However, if the step is generally part of the
job it should be listed.

A hazard is a potential danger. The purpose of
the Job Safety Analysis is to identify all hazards,
both those produced by the environment or
conditions and those connected with the job
procedure.

To identify hazards, ask yourself these questions
about each step:

1. Is the danger of the employee striking
against, being struck by, or otherwise making
injurious contact with an object?

2. Can the employee be caught in, by or
between objects?

3. Is there potential for slipping, tripping, or
falling?

4. Could the employee suffers strains from
pushing, pulling, lifting, bending, or twisting?

5. Is the environment hazardous to safety
and/or health (toxic gas, vapor, mist, fumes,
dust, heat, or radiation)?.

Close observations and knowledge of the job is
important. Examine each step carefully to find
and identify hazards; the actions, conditions and
possibilities that could lead to an accident.
Compiling an accurate and complete list of
potential hazards will allow you to develop the
recommended safe job procedures needed to
prevent accidents.

Using the first two columns as a guide, decide
what actions or procedures are necessary to
eliminate or minimize the hazards that could lead
to an accident, injury, or occupational illness.

Begin by trying:
1. Engineer the hazard out: 2. provide guards,
safety devices, etc.; 3. provide personal
protective equipment; 4. provide job instruction
training; 5. maintain good housekeeping; 6.
insure good ergonomics (positioning the person in
relation to the machine or other elements in such
a way as to improve safely).

List the recommended safe operating procedures.
Begin with an action word. Say exactly what
needs to be done to correct the hazard, such as,
lift using your leg muscles. Avoid general
statements such as be careful.

List the required or recommended personal
protective equipment necessary to perform each
step of the job.

Give a recommended action or procedure for each
hazard.
Serious hazards should be corrected immediately.
The JSA should then be changed to reflect the
new conditions.
Finally, review your input on all three columns for
accuracy and completeness. Determine if the
recommended actions or procedures have been
put in place. Re-evaluate the job safety analysis
as necessary.

Who is responsible? Write
the person (receiver)
responsible
(Supervisor/Work Permit
Issuer receiver/contractor)
to implement the control
measures identified.