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JSA Form Template

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JSA Form Template

Job Safety Analysis (JSA)

Job Task Being Assessed

Job description

Select job type

Specify job type

List employees observed during JSA

Tasks, Hazards and Preventive Measures

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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