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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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