Templates
JSA Form Template

JSA Form Template

Use this JSA template for observations of workers performing individual tasks, identification hazards and preventive measures and controls.

Use this template
or download pdf
JSA Form Template

Use this JSA template for observations of workers performing individual tasks, identification hazards and preventive measures and controls.

Use this template
or download pdf

Related categories

Preview of the 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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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.