JSA Form Template - Free Checklist

1) Break a job into smaller tasks and observe a worker while doing the tasks 2) Click + to add additional steps or fill in relevant information 3) Identify any potential hazards for each task 4) Determine preventive measures to overcome these hazards

Enter job description

Potential risk or hazard you identified while task was performed (select 1 or more)

Enter other potential risks

Rate risk/ hazard before measures are taken

Take a photo of step or activity (Optional)

Risk Control Measures

Administrative Controls

Other measures

Personal Protective Equipment (PPE)

Engineering Controls

Explanation of control measures

Recommendation from Health and Safety Committee

Recommendations

Completion

Name and Signature of Inspector

Name and Signature of Health and Safety Committee Member

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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.