WHS_001F_JobSafetyAnalysis_VersionB

JOB SAFETY ANALYSIS (JSA)

WHS_001F
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CLIENT
JSA COMPLETED BY
LOCATION
This is physical location - 6 Cord Street, Dudley Park
DATE

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Time

Hour Minutes

AM/PM Option
WORK ACTIVITY /TASK DESCRIPTION
ARE THERE ANY OF THE FOLLOWING HAZARDS?

Any hazards ticked must be addressed below
Type a question

Other
RISK MATRIX
Probability (Likelihood it will happen)
Rare – Highly unlikely, minimal impact
Unlikely – Possible but uncommon
Possible – May occur occasionally
Likely – Expected to happen regularly
Almost Certain – Will happen frequently
Severity (Impact)
Low – No significant harm
Minor – Mild injury or damage
Moderate – Medical attention needed
Severe – Serious harm or disability
Major – Fatality or extreme loss
REQUIRED PPE
Type a question
HIERARCHY OF CONTROL
Level 4 | Engineering

Level 5 | Administration

Level 6 | PPE
Level 4 | Engineering

Level 5 | Administration

Level 6 | PPE
Job Steps 1
In order of Activity
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating (Prior to Controls)
From Risk Matrix above, i.e. M9
Control Measures
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
If you have more Potential Hazards to add to the Job Step, please repeat the Job Step to continue adding Control Measures.
Job Steps 2
In order of Activity
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
If you have more Potential Hazards to add to the Job Step, please repeat the Job Step to continue adding Control Measures.
Job Steps 3
In order of Activity
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
If you have more Potential Hazards to add to the Job Step, please repeat the Job Step to continue adding Control Measures.
Job Steps 4
In order of Activity
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
If you have more Potential Hazards to add to the Job Step, please repeat the Job Step to continue adding Control Measures.
Job Steps 5
In order of Activity
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
If you have more Potential Hazards to add to the Job Step, please repeat the Job Step to continue adding Control Measures.
Job Steps 6
In order of Activity
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
Are there additional hazards for the same job step?
Potential Hazard
List 1 hazard at a time
Risk Matrix Rating
From Risk Matrix above, i.e. M9
Control Measures
Address all hazards selected above i.e. drowning
Residual Risk Matrix Rating
From Risk Matrix above, i.e. now M6 with controls
Team Member Responsible
Who is responsible for these controls?
WORKERS INVOLVED IN JOB TASK
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name
Company
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
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JOB SAFETY ANALYSIS (JSA)

ARE THERE ANY OF THE FOLLOWING HAZARDS?

RISK MATRIX

REQUIRED PPE

HIERARCHY OF CONTROL

WORKERS INVOLVED IN JOB TASK