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JSA Blank Form

This document contains a job safety analysis worksheet template for analyzing potential hazards in a job or task. The worksheet collects information about the job such as required training, description of tasks, tools and equipment used, physical requirements, weight lifted, pushed or pulled, environmental conditions, protective equipment needs and allows for noting identified potential hazards and controls to prevent incidents. It is intended to be completed by those performing the job analysis and approved by supervisors to improve workplace safety.

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Ruppee Edward
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
195 views6 pages

JSA Blank Form

This document contains a job safety analysis worksheet template for analyzing potential hazards in a job or task. The worksheet collects information about the job such as required training, description of tasks, tools and equipment used, physical requirements, weight lifted, pushed or pulled, environmental conditions, protective equipment needs and allows for noting identified potential hazards and controls to prevent incidents. It is intended to be completed by those performing the job analysis and approved by supervisors to improve workplace safety.

Uploaded by

Ruppee Edward
Copyright
© Attribution Non-Commercial (BY-NC)
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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JOB SAFETY ANALYSIS WORKSHEET

Department: Job Analyzed: Task Completed By: Location: Analysis By: Approved By: Required Personal Protective and Emergency Equipment Date Completed: Supervisor: Reviewed By:

SEQUENCE OF JOB STEPS

POTENTIAL HAZARDS

CONTROLS/ PREVENTION MEASURES

PAEC JSA Blank Form.doc Risk/Safety Mnaual April 2003

JOB SAFETY ANALYSIS Worksheet Location of Job or Task: Employee performing Job or Task: 1. Job or Task title :

2. Training required to complete job/task:

3. Detailed description of job as currently completed

4. Types of tools, equipment, vehicles, materials or machines used in job:

5.

Amount of job/task spent: Standing -

Walking Sitting

6.

Job /task is Inside buildings; Outside( exposed to weather)

7. While performing the job, the employee is required to:

PAEC JSA Blank Form.doc Risk/Safety Mnaual April 2003

Description Twisting Stoop or bend Squat Kneel Crawl Climb Ladders Climb Stairs Walk on uneven ground Grasp, or feel Work above ground Operate vehicle/equipment Other

Yes

No

How often:

How long per day:

8. The heaviest weight lifted while sitting or standing in one place weighs:

Object lifted:

Average times lifted daily:

Size of object:

The object is lifted from:

to:

9. The heaviest weight lifted while walking weighs:

pounds

Object lifted: ______________________Average times lifted daily: _____________________ Size of object: _____________________ The object is lifted from: _______________to: _______________________ 10. The heaviest weight pushed/pulled weighs: _____________ pounds.
PAEC JSA Blank Form.doc Risk/Safety Mnaual April 2003 3

Object: ___________________________Average times pushed or pulled daily:_________________________________ Distance pushed or pulled: _______________________________________

11. Visual and Hearing Requirements: Talking: Ordinary Conversation: _________Above Noise: _________________________ Hearing: Ordinary Conversation: _________ Above Noise :_________________________ Vision: Near: ________ Far: ____________ Depth Perception: ______________________ Color: __________ Field of Vision: ______________________

PAEC JSA Blank Form.doc Risk/Safety Mnaual April 2003

12. Physical Activity Required: Activity Lifting <10 lbs 10-25 lbs 25-50 lbs 50<lbs Carrying : Under 10 lbs 10-25 lbs 25-50 lbs 50<lbs Reaching : Above Shoulder At Shoulder Below Shoulder Never Frequency per hour Under one hour Hours performed daily 1-2 3-4 5-6

7-8

PAEC JSA Blank Form.doc Risk/Safety Mnaual April 2003

13. Job/ Task Environment: Check those applicable and make comments ? Description Chemicals Heat/Cold Confined Space Contact with Public/Customers Water, Dampness Dust Electrical Hazards Emotional Demands Explosives Fumes Chemical Vapors/Mist Lighting critical to task Machine paced work Odors Noise estimated decibel: Vibration Skin irritation Radiation Type: Sun Work at heights Working alone Other: Comments

14. Protective equipment worn: ___________________________________________________________________________________________________________ 15. Additional Summary Comments:

Date: __________________ Completed By:_____________________________ Title:_________________________________


PAEC JSA Blank Form.doc Risk/Safety Mnaual April 2003 6

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