Job Safety Analysis (JSA)

Job Safety Analysis (JSA)
Date

MonthDayYear
Date
Is this JSA:
JSA Number
Do personnel require a licence / ticket / permit / trade skill / other:
Specify:
Exact Location: e.g. Crushing Plant
Task: e.g. Removal and replacement of screens
Reference Materials: e.g. Equipment Manufacturers operation and maintenance manual
Once developed, the JSA must be signed below by each JSA team member involved in the development of the JSA.

JSA TEAM MEMBERS

Rows	Name	Position
1
2
3
4
5

Signature - Team Member 1
Signature - Team Member 2
Signature - Team Member 3
Signature - Team Member 4
Signature - Team Member 5
This JSA is not valid until signed by the Site Supervisor or nominee. Each section of the worksheet must be completed before it can be validated and before work can start.
Authorisation
Site Supervisor Nominee
Full name
Signature
Date

MonthDayYear
Date
JSA Team Leader
Full name
Signature
Date

MonthDayYear
Date
HAZARDS / ENERGY
NOISE - Acoustic Mechanical Vibrations Energy: Would you have to shout to be heard less than a metre away from the person to whom you’re speaking?
HEAT - Thermal Energy: Is there a risk of burns / scalds, cold burns, heat exhaustion, sunburn?
LIGHTING - Is the lighting good enough to see where you are and what you are doing clearly?
AIRBORNE SUBSTANCES - Chemical Energy: Are there any airborne contaminants released or generated when performing this task?
If so, what sort are they?
e.g. welding fumes, dusts, etc.
CHEMICALS - Chemical Energy: Does the task involve the handling or the use of chemicals?
If yes, please list the types of chemicals.
e.g. sodium chlorate, diesel, etc.)
GASES - Chemical Energy: Are there any gasses released or generated when performing this task?
If so what sort are they?
e.g smells, SO2 etc.
PLANT, MACHINES AND EQUIPMENT - Kinetic or Potential Energy: Are plant, conveyors and / or machine moving parts exposed which can be guarded?
PLANT, MACHINES AND EQUIPMENT - Kinetic or Potential Energy: Are additional emergency stop mechanisms required to prevent risk of injury?
PLANT, MACHINES AND EQUIPMENT - Kinetic or Potential Energy: Are there any potential electrical, mechanical or pneumatic hazards?
HAND TOOLS - Biomechanical Energy: Will the task require the use of hand tools?
HAZARDOUS MANUAL TASKS - Biomechanical Energy: Will you perform any of the following actions repeatedly?
Bend down
Reach above your head
Reach forward
Twist (at waist line)
Maintain an awkward posture
Are actions repeated frequently?
Do you manually move loads over long distances?
Does the task involve pushing, pulling or carrying loads?
Could an injury occur as a result of a person falling?
Is a person required to work where there is a risk of falling from one level to another?
Is a Fall Injury Protection System the principle means of protection?
Does a person need to exit from an elevated work platform (EWP) in the raised position?
Creating an open hole with edge protection, floor or walkway?
Scaffolding is to be erected or dismantled?
Is work to occur on or near the edge of a fragile surface?
Could an injury occur as a result of an object falling?
Are other jobs/tasks in progress which could pose an interaction risk to employees carrying out this task?
Are there other jobs/tasks in progress which could be put at risk by carrying out this task?
Is there a risk from accidental falling objects, spillage or other interactions, accidental or otherwise, between this task and any other concurrent tasks being carried out?
Does the task/job require personnel, materials or equipment to be lifted such that a suspended load risk is created?

Rows	Step	Job Tasks	Hazards	Existing Controls	Assess Risk (Initial rank)	Additional Controls	Assess Risk (Residual rank)
1
2
3
4
5
6

Rows	Step	Job Tasks	Hazards	Existing Controls	Assess Risk (Initial rank)	Additional Controls	Assess Risk (Residual rank)
7
8
9
10
11
12

All Personnel working under this JSA must sign off below to acknowledge they have read, understood and accepted the conditions stipulated

Rows	Name	Position	Date	Time
1
2
3
4
5
6

Signature - Person 1
Signature - Person 2
Signature - Person 3
Signature - Person 4
Signature - Person 5
Signature - Person 6

CHANGES to the JSA

Rows	Job Tasks	Hazards	Existing Controls	Assess Risk (Initial rank)	Additional Controls	Assess Risk (Residual rank)
Step 1
Step 2

Installer 1 - Email Address
example@example.com
Installer 2 - Email Address
example@example.com
Installer 3 - Email Address
example@example.com
Installer 4 - Email Address
example@example.com
Installer 4 - Email Address
example@example.com
Installer 5 - Email Address
example@example.com
Installer 6 - Email Address
example@example.com
Should be Empty:

Job Safety Analysis (JSA)

HAZARDS / ENERGY