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This Job Safety Analysis form is used to examine contracted work tasks and modify them to minimize risks of injury or damage. It must be completed before tasks that involve working at heights, near electricity, with hazardous substances, excavation, demolition, confined spaces, or near roadways. The form lists the task, potential hazards, risks, required licenses and equipment, and responsibilities for controlling risks. The manager endorses the analysis to be aware of the contractor's intended work.

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joel walker
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43 views2 pages

Form

This Job Safety Analysis form is used to examine contracted work tasks and modify them to minimize risks of injury or damage. It must be completed before tasks that involve working at heights, near electricity, with hazardous substances, excavation, demolition, confined spaces, or near roadways. The form lists the task, potential hazards, risks, required licenses and equipment, and responsibilities for controlling risks. The manager endorses the analysis to be aware of the contractor's intended work.

Uploaded by

joel walker
Copyright
© © All Rights Reserved
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

This Job Safety Analysis (JSA) form is completed to critically examine a contracted work task and where required to alter that task to ensure that the risk of personal or property
damage is minimized. Contractor JSA or Safe Work Method Statement (SWMS) templates can also be accepted.
This JSA must be completed prior to commencement of the following tasks to confirm acceptable levels of risk control:

 working from height  working on or near live electricity


 using hazardous substances and
 Isolating fire system  excavation work
dangerous goods  demolition or structural alterations
 working with installed  entry to confined spaces
 asbestos removal or disturbance  Work adjacent to roadways
plant
Name of
Name of Contractor/s
Company

Work order
Date Project number
number

Reviewed by
JSA prepared by
UoW manager

Description of the job:

Items of plant, tools and equipment to skills/competencies/licenses


Any relevant safe work procedures Protective equipment required:
be used required for safe job performance

Overalls Footwear

Hearing Sunscreen
protection
Eye protection
Hard hat
Cut proof trouser
Gloves
Other
High visibility
vests

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Job Safety Analysis Worksheet

Potential Who is responsible for


Process task Risks Risk control measures
hazards controlling the risk?

Against each For each


List the task required
task list the hazard describe Describe the intended risk control measures. Apply the Hierarchy of
to perform the job in List the person responsible for
hazard(s) that the level of risk Control: elimination, substitution, engineering controls, administrative
the sequence they controlling each risk.
could cause that may be controls and protective equipment.
are carried out.
injury. present.

Comments:

UoW Manager / Manager / Supervisor Name Signature Date


Supervisor
Endorsement

This endorsement is to ensure that the manager is aware of the intended work of the contractor. It is not necessary for the manager to have a specific knowledge
of work task or controls. Refer to line manager or H&S Consultant for further advice if required.

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