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JSA Form Template

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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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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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