JOB SAFETY ANALYSIS (JSA)

Company: [COMPANY NAME]
Job/Task: [JOB/TASK NAME]
Location: [WORK LOCATION]
Date Prepared: [DATE]
Prepared by: [NAME & POSITION]
Reviewed by: [NAME & POSITION]
Approved by: [NAME & POSITION]

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SECTION 1: JOB INFORMATION

Job Title: [SPECIFIC JOB TITLE]
Department: [DEPARTMENT]
Job Location: [SPECIFIC LOCATION]
Equipment Used: [LIST ALL EQUIPMENT]
Materials Used: [LIST ALL MATERIALS]
Number of Workers: [NUMBER]
Estimated Time: [DURATION]
Frequency: □ Daily □ Weekly □ Monthly □ Occasional

SECTION 2: WORKER INFORMATION

Primary Worker: [NAME]
Experience Level: □ Experienced □ Intermediate □ New
Training Required: [LIST REQUIRED TRAINING]
Certifications Needed: [LIST CERTIFICATIONS]
Medical Restrictions: [ANY RESTRICTIONS]

Additional Workers:
Worker 2: [NAME] - Experience: [LEVEL]
Worker 3: [NAME] - Experience: [LEVEL]
Worker 4: [NAME] - Experience: [LEVEL]

SECTION 3: PERSONAL PROTECTIVE EQUIPMENT

Required PPE for this job:
□ Hard hat/Safety helmet
□ Safety glasses/goggles
□ Hearing protection
□ Respiratory protection
□ Safety gloves (specify type): [TYPE]
□ Safety footwear
□ High-visibility clothing
□ Fall protection equipment
□ Chemical-resistant clothing
□ Other: [SPECIFY]

PPE Inspection Requirements:
• Inspect before each use
• Replace damaged equipment immediately
• Store properly when not in use
• Follow manufacturer's instructions

SECTION 4: ENVIRONMENTAL CONDITIONS

Work Environment:
□ Indoor □ Outdoor □ Confined space □ Elevated work
□ Hot environment □ Cold environment □ Wet conditions
□ Dusty conditions □ Noisy environment □ Poor lighting

Weather Considerations:
□ Temperature restrictions
□ Wind speed limitations
□ Precipitation restrictions
□ Visibility requirements

Special Conditions:
[DESCRIBE ANY SPECIAL ENVIRONMENTAL FACTORS]

SECTION 5: JOB SAFETY ANALYSIS BREAKDOWN

STEP 1: [DESCRIBE FIRST STEP OF JOB]
Potential Hazards:
• [HAZARD 1]
• [HAZARD 2]
• [HAZARD 3]

Recommended Safe Practices:
• [SAFE PRACTICE 1]
• [SAFE PRACTICE 2]
• [SAFE PRACTICE 3]

Required Controls:
• [CONTROL MEASURE 1]
• [CONTROL MEASURE 2]

STEP 2: [DESCRIBE SECOND STEP OF JOB]
Potential Hazards:
• [HAZARD 1]
• [HAZARD 2]
• [HAZARD 3]

Recommended Safe Practices:
• [SAFE PRACTICE 1]
• [SAFE PRACTICE 2]
• [SAFE PRACTICE 3]

Required Controls:
• [CONTROL MEASURE 1]
• [CONTROL MEASURE 2]

STEP 3: [DESCRIBE THIRD STEP OF JOB]
Potential Hazards:
• [HAZARD 1]
• [HAZARD 2]
• [HAZARD 3]

Recommended Safe Practices:
• [SAFE PRACTICE 1]
• [SAFE PRACTICE 2]
• [SAFE PRACTICE 3]

Required Controls:
• [CONTROL MEASURE 1]
• [CONTROL MEASURE 2]

STEP 4: [DESCRIBE FOURTH STEP OF JOB]
Potential Hazards:
• [HAZARD 1]
• [HAZARD 2]
• [HAZARD 3]

Recommended Safe Practices:
• [SAFE PRACTICE 1]
• [SAFE PRACTICE 2]
• [SAFE PRACTICE 3]

Required Controls:
• [CONTROL MEASURE 1]
• [CONTROL MEASURE 2]

STEP 5: [DESCRIBE FIFTH STEP OF JOB]
Potential Hazards:
• [HAZARD 1]
• [HAZARD 2]
• [HAZARD 3]

Recommended Safe Practices:
• [SAFE PRACTICE 1]
• [SAFE PRACTICE 2]
• [SAFE PRACTICE 3]

Required Controls:
• [CONTROL MEASURE 1]
• [CONTROL MEASURE 2]

[Continue for additional steps as needed]

SECTION 6: HAZARD CATEGORIES CHECKLIST

Physical Hazards:
□ Struck by objects
□ Caught in/between
□ Falls from height
□ Slips/trips/falls
□ Cuts/lacerations
□ Burns/scalds
□ Electrical shock
□ Noise exposure
□ Vibration
□ Temperature extremes

Chemical Hazards:
□ Toxic exposure
□ Corrosive materials
□ Flammable substances
□ Respiratory hazards
□ Skin/eye contact
□ Ingestion risk

Biological Hazards:
□ Infectious agents
□ Contaminated materials
□ Animal/insect exposure
□ Allergenic substances

Ergonomic Hazards:
□ Heavy lifting
□ Repetitive motions
□ Awkward postures
□ Forceful exertions
□ Contact stress

Psychosocial Hazards:
□ Work stress
□ Fatigue
□ Time pressure
□ Isolation
□ Violence potential

SECTION 7: EMERGENCY PROCEDURES

Emergency Contacts:
Emergency Services: 911
Company Emergency: [NUMBER]
Supervisor: [NAME & NUMBER]
Safety Manager: [NAME & NUMBER]
First Aid Personnel: [NAME & NUMBER]

Emergency Equipment Locations:
First Aid Kit: [LOCATION]
Fire Extinguisher: [LOCATION]
Emergency Shower: [LOCATION]
Eye Wash Station: [LOCATION]
Emergency Phone: [LOCATION]

Emergency Response Steps:
1. Ensure scene safety
2. Provide immediate first aid
3. Call for emergency assistance
4. Notify supervisor
5. Secure the work area
6. Complete incident report

SECTION 8: TRAINING REQUIREMENTS

Required Training:
□ General safety orientation
□ Job-specific safety training
□ Equipment operation training
□ PPE training
□ Emergency response training
□ Hazard communication training
□ Fall protection training (if applicable)
□ Confined space training (if applicable)
□ Lockout/tagout training (if applicable)

Training Documentation:
Training Provider: [NAME]
Training Date: [DATE]
Certification Valid Until: [DATE]
Refresher Training Due: [DATE]

SECTION 9: PERMITS AND AUTHORIZATIONS

Required Permits:
□ Hot work permit
□ Confined space permit
□ Excavation permit
□ Work at height permit
□ Electrical work permit
□ Chemical handling permit
□ Other: [SPECIFY]

Authorization Requirements:
□ Supervisor approval
□ Safety department approval
□ Maintenance coordination
□ Operations coordination
□ Environmental approval

SECTION 10: QUALITY CONTROL CHECKPOINTS

Inspection Points:
Checkpoint 1: [DESCRIPTION]
Frequency: [FREQUENCY]
Inspector: [TITLE]
Documentation: [FORM/RECORD]

Checkpoint 2: [DESCRIPTION]
Frequency: [FREQUENCY]
Inspector: [TITLE]
Documentation: [FORM/RECORD]

Checkpoint 3: [DESCRIPTION]
Frequency: [FREQUENCY]
Inspector: [TITLE]
Documentation: [FORM/RECORD]

SECTION 11: RISK ASSESSMENT

Overall Risk Level:
□ Low Risk (1-6)
□ Medium Risk (7-12)
□ High Risk (13-25)

Risk Calculation:
Likelihood: [1-5]
Consequence: [1-5]
Risk Rating: [L × C]

Risk Acceptability:
□ Risk acceptable with current controls
□ Risk acceptable with additional controls
□ Risk unacceptable - job cannot proceed

SECTION 12: COMMUNICATION PLAN

Pre-Job Briefing:
□ Review JSA with all workers
□ Discuss specific hazards
□ Confirm understanding of procedures
□ Verify PPE requirements
□ Review emergency procedures

During Job Communication:
□ Maintain radio contact
□ Use standard hand signals
□ Conduct safety checks
□ Report changes in conditions
□ Stop work for safety concerns

Post-Job Review:
□ Debrief on safety performance
□ Identify improvement opportunities
□ Update JSA if needed
□ Document lessons learned

SECTION 13: CONTINUOUS IMPROVEMENT

Review Triggers:
□ Incident or near-miss
□ Change in procedure
□ New equipment introduction
□ Worker feedback
□ Annual review

Update Process:
1. Identify need for revision
2. Gather input from workers
3. Revise JSA content
4. Review and approve changes
5. Communicate updates
6. Retrain affected workers

SECTION 14: APPROVAL AND AUTHORIZATION

JSA Prepared by: _________________ Date: _______
[NAME & POSITION]

Technical Review by: ______________ Date: _______
[SUBJECT MATTER EXPERT]

Safety Review by: ________________ Date: _______
[SAFETY MANAGER]

Supervisor Approval: _____________ Date: _______
[SUPERVISOR NAME]

Management Approval: _____________ Date: _______
[MANAGER NAME]

SECTION 15: WORKER ACKNOWLEDGMENT

I have read and understand this Job Safety Analysis. I agree to 
follow all safety procedures and use required protective equipment.

Worker 1: _______________________ Date: _______
[PRINT NAME & SIGN]

Worker 2: _______________________ Date: _______
[PRINT NAME & SIGN]

Worker 3: _______________________ Date: _______
[PRINT NAME & SIGN]

Worker 4: _______________________ Date: _______
[PRINT NAME & SIGN]

SECTION 16: DOCUMENT CONTROL

Document Information:
JSA Number: [JSA-XXX]
Version: 1.0
Effective Date: [DATE]
Review Date: [DATE]
Next Update: [DATE]

Distribution:
□ Work Crew
□ Supervisor
□ Safety Department
□ Training Department
□ File Copy

SECTION 17: RELATED DOCUMENTS

Reference Documents:
• Safety Procedures Manual
• Equipment Operating Manuals
• Safety Data Sheets
• Emergency Response Plan
• Training Records
• Permit Requirements
• Regulatory Standards

NOTES AND ADDITIONAL INFORMATION:
_________________________________________________________________
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This JSA must be reviewed with all workers before beginning work 
and should be readily available at the job site for reference.