Draft Job Safety Analysis (JSA) Planning Form

Emergency Notification
Job Contacts
Organizational Procedures

Examine each step carefully to find and identify hazards or potential dangers that could lead to injury, illness, or facility/equipment damage.

Examples include:

Chemical Hazards

  • Inhalation
  • Skin Contact
  • Absorption
  • Injection
  • Ingestion

Biological Hazards

  • Bloodborne Pathogens
  • Mold
  • Valley Fever
  • Plant/Insect/Animal

Physical Hazards

  • Electrical
  • Fire/Explosion
  • Noise
  • Radiation
  • Thermal Stress
  • Pinch Point/Line of Fire
  • Slips/Falls
  • Strike Against/Struck By

Ergonomic Hazards

  • Repetition
  • Forceful Exertion
  • Awkward Posture
  • Contact Stress
  • Vibration
  • Work Area Design
JSA Version
Date Work is to be Performed

Key Individuals

Field Supervisor
Organization Oversight

Job Team Members (select + to add up to 11 additional)

Major Issues to Address

Are all team members trained and authorized to issue Stop Work Authority if they see a reason?
Are all team members properly trained, certified (if appropriate) and experienced for this job?
Is the team properly equipped to insure the job is completed incident and industry free?

Job/Task Procedure Steps (select + to add up to 19 additional)

Confirmation by Field Supervisor All Steps are Accomplished as Required

HSE Requirements

Personal Protective Equipment Required (Select All Required)
Permits and Safe Work Plans Required (Select All Required)
Gas Detection Required (Select All Required)
Hazardous Substance Reviewed and Addressed
Site Control

Environemnt

Hazardous Energy Control

Tools and Equipment

Tool/Equipment Status

Major Tools/Equipment Used on this Job/Task (select + to add up to 9 additional)

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.
Upload any documentation, manuals, diagrams, charts, and photos, etc. necessary to perform the job tasks safely, in an environmental friendly and timely manner.
Responsible Individual Completing Analysis

End of JSA

JSA Reviewed by:

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