Job Safety Analysis (JSA) Form

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A JSA-template is a useful tool for monitoring high-risk tasks. It can be broken down into individual steps to better recommend corrective actions by first noting information about the workplace and the employee involved in the inspection. The risk assessment form prompts the inspector to add steps, identify and record hazards, evaluate the analyzed risk and recommend preventive measures.

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Job Safety Analysis (JSA) Form

Information regarding site

number of work order

task activity

date

Site number or name

name of contractor or subcontractor

Check applicable, anticipated or potential hazards

Underground tank removal/Disposable/High vapors

Demolition

Activities in/ near traffic areas

Concrete cutting/ coring

Mobile heavy equipment activities (excavators, dump trucks, vacuum and hydrovac trucks)

Pile driving or shoring

Work which affects integrity of critical controls

Welding, cutting or grinding

Hydroblasting or sand blasting

Radiography or X-Ray testing

pressure testing

Other (please specify) :

critical procedures: when work involves any of these hazards it must be incorporated into JSA

Work at heights above 1,5m

Confined space entry (also during tank cleaning)

Electrical/Mechanical lockouts (live, lock out / tag out, isolation,)

Heavy equiptment lifting (cranes, excavators, boom trucks)

Drilling borehole or excavations (locates, sub-surface clearance)

Entry into excavations/Trenches: 1,2m deep

Hot work (in possibly explosive atmospheres)

Make sure that all hazards identified are addressed in JSA below

(A) sequence of basic job steps in order

(A) potential hazards (e.g. hazard zone, underground services etc.)

(A) safety control to reduce or eliminate hazards

(B) sequence of basic job steps in order

(B) potential hazards. (e.g. hazard zone, underground services etc.)

(B) safety controls to reduce or eliminate hazard

(C) sequence of basic job steps in order

(C) potential hazards (e.g. underground services, hazard zone etc.)

(C) safety controls to reduce or eliminate a hazard

(D) sequence of basic job steps in order

(D) potential hazards (e.g. underground services, hazard zone etc.)

(D) safety controls to reduce or eliminate hazard

(E) sequence of basic job steps in order

(E) potential hazards (e.g. underground services, hazard zone etc.)

(E) safety controls to reduce or eliminate a hazard

Equipment ( list of equipment and its storage on site, only if relevant to safety)

List

additional PPE ( minimum requirement: gloves, glasses, hard hat, safety boots, visi-vest)

Hearing protection

Fall protection

Eye protection

Portable gas monitor

Rubber footwear and gloves if in a damp area

Other (fire retardant coveralls, breathing apparatus, etc) specify :

relevant outside authorities:

(check name not set)

outside authorities (signature)

disposal of designated substances, surplus, or impacted materials (including details)

(check name not set)

signature

retailer or sales associate

prepared by (please sign)

date

person carrying out the work (please sign)

date

person carrying out work (please sign)

date

person carrying out work (please sign)

date

site supervisor

JSA approved retailer or sales associate (please sign)

date

Download this checklist