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Jsa Form

JSA is the analytical process of: • Identifying the basic job steps of the task, • For every job step, reviewing associated potential safety and health hazards, and • Planning for effective controls or safeguarding mechanism to control (i.e., eliminate or mitigate) the effects the hazards may pose.

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Strauhs Equipamentos
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87 views1 page

Jsa Form

JSA is the analytical process of: • Identifying the basic job steps of the task, • For every job step, reviewing associated potential safety and health hazards, and • Planning for effective controls or safeguarding mechanism to control (i.e., eliminate or mitigate) the effects the hazards may pose.

Uploaded by

Strauhs Equipamentos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Sample 

Comprehensive JSA Form
Job Name:
Job Location: Date: JSA #: For Permitted Work, indicate PTW#:
Supervisor: Participants:
Summary of Job:
List Associated SOPs or SEMS procedures:

Severity
Risk Tolerability Matrix Minor Serious Severe
• Insignificant to first aid injury • Serious injury and loss time • Fatalities
Potential Likelihood • Slight leak, spill contained • Significant spill • Major uncontained spill
Frequent (more than 1 in 1,000
Medium High High
chance of occurrence)
Seldom (between 1 in 1,000 and 1
Low Medium High
in 100,000 chance of occurrence)
Unlikely (less than 1 in 100,000
Low Low Medium
chance of occurrence)
Consider available additional controls to further 
 Task cannot proceed under normal                    
Risk Tolerability Criteria >> Existing controls satisfactory.Task can proceed. reduce risk. Task can proceed under careful 
circumstances. Risk must be reduced
monitoring

Sequence of Potential Potential Safety & Controls and Responsible for Control Verification (Name and


Severity Likelih’d Risk
Tasks Hazards Envir.Consequences Barriers Signature)
Task 1…. a) a) a)
b) b) b)

Task 2…. a) a) b)

Task 3…. a) a) a)

Other ENVIRONMENTAL/ Controls and barriers: Verified by:


SECURITY concerns:

⃝ Fall Arrest ⃝ Face/Eye ⃝  Hearing


Harness Protection Protection ⃝  Hard Hat ⃝ Respirator ⃝  Gloves ⃝  Protective Clothing ⃝ Safety Shoes ⃝  Goggles ⃝  Type V/III PFD
List Additional PPE required
I have participated in this JSA and understand the information contained herein.
Signature: __________________________________
Signature: __________________________________
Signature: __________________________________
Signature: __________________________________

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