Job Safety Analysis (JSA) Form
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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Cut inspection time by 50% Uncover more issues and solve them 4x faster Select from over 4000 expert-proofed templates Job Safety Analysis (JSA) Form Information regarding site Check applicable, anticipated or potential hazards Underground tank removal/Disposable/High vapors Safe At Risk N/A Demolition Safe At Risk N/A Activities in/ near traffic areas Safe At Risk N/A Concrete cutting/ coring Safe At Risk N/A Mobile heavy equipment activities (excavators, dump trucks, vacuum and hydrovac trucks) Safe At Risk N/A Pile driving or shoring Safe At Risk N/A Work which affects integrity of critical controls Safe At Risk N/A Welding, cutting or grinding Yes No N/A Hydroblasting or sand blasting Yes No N/A Radiography or X-Ray testing Yes No N/A pressure testing Yes No N/A Other (please specify) : Yes No N/A critical procedures: when work involves any of these hazards it must be incorporated into JSA Work at heights above 1,5m Yes No N/A Confined space entry (also during tank cleaning) Yes No N/A Electrical/Mechanical lockouts (live, lock out / tag out, isolation,) Yes No N/A Heavy equiptment lifting (cranes, excavators, boom trucks) Yes No N/A Drilling borehole or excavations (locates, sub-surface clearance) Yes No N/A Entry into excavations/Trenches: 1,2m deep Yes No N/A Hot work (in possibly explosive atmospheres) Yes No N/A Make sure that all hazards identified are addressed in JSA below Equipment ( list of equipment and its storage on site, only if relevant to safety) additional PPE ( minimum requirement: gloves, glasses, hard hat, safety boots, visi-vest) Hearing protection Yes No N/A Fall protection Yes No N/A Eye protection Yes No N/A Portable gas monitor Yes No N/A Rubber footwear and gloves if in a damp area Yes No N/A relevant outside authorities: outside authorities (signature) disposal of designated substances, surplus, or impacted materials (including details) retailer or sales associate prepared by (please sign) person carrying out the work (please sign) person carrying out work (please sign) person carrying out work (please sign) site supervisor JSA approved retailer or sales associate (please sign)