JOB HAZARD ANALYSIS TEMPLATE

Use this template to conduct more detailed hazard analysis in your workplace. Explore the features of Lumiform and modify the checklist based on your workplace needs. Start by listing the names of the people who develops JSA procedures, and select the work permits, authorizations and PPE required for the activity. Next enumerate applicable trainings to carry out individual tasks. 

 

Also, take note of the equipment checks conducted. Proceed with the job safety analysis and risk assessment by adding steps, selecting hazards and identifying controls. Conduct an initial risk assessment, add controls (if needed), then rate the residual/revised risk analysis. Confirm whether the process is completed or not. If not, conduct a task review to serve as a basis for the continuity of the process. Finally, acknowledge by getting all people involved to sign off.

 

WME JOB SAFETY ANALYSIS

JSA Details

• Full Name & Role

Work Permits / Authorizations Required

Select applicable work permit or authorization required

• Working at Heights
• High Voltage
• Confined Space
• Notifiable Work
• Crane Work
• Hot Work
• Isolation (Lock out)
• Hazardous Work
• Excavation & Trenching
• Traffic Management Plan
• Other

Enter other necessary work permit

Safety Equipment Required

Select applicable safety equipment required for the job

• Working at Heights
• High Voltage
• Confined Space
• Notifiable Work
• Crane Work
• Hot Work
• Isolation (Lock out)
• Hazardous Work
• Excavation & Trenching
• Traffic Management Plan
• Other

Competencies & Trainings

List any applicable competencies & training to carry out specific tasks.

Equipment Check & Special Considerations

List down checked equipment & special considerations

Job Safety Analysis & Risk Assessment

Job Step / Tasks and Risk Analysis

Enlist the job step tasks, hazards or controls etc.

• Step in Process / Task

• Hazards

People

• Working at Heights
• High Voltage
• Confined Space
• Notifiable Work
• Crane Work
• Hot Work
• Isolation (Lock out)
• Hazardous Work
• Excavation & Trenching
• Traffic Management Plan
• Other

Work Environment

• Working at Heights
• High Voltage
• Confined Space
• Notifiable Work
• Crane Work
• Hot Work
• Isolation (Lock out)
• Hazardous Work
• Excavation & Trenching
• Traffic Management Plan
• Other

Environmental

• Working at Heights
• High Voltage
• Confined Space
• Notifiable Work
• Crane Work
• Hot Work
• Isolation (Lock out)
• Hazardous Work
• Excavation & Trenching
• Traffic Management Plan
• Other

Equipment / Machinery

• Working at Heights
• High Voltage
• Confined Space
• Notifiable Work
• Crane Work
• Hot Work
• Isolation (Lock out)
• Hazardous Work
• Excavation & Trenching
• Traffic Management Plan
• Other

Consequence

• Rare
• Unlikely
• Possible
• Likely
• Almost Certain

Likelihood

• Insignificant
• Minor
• Moderate
• Major
• Catastrophic

Risk Rating

• Existing Controls

• Initial Risk Analysis

Additional Controls

• Revised Risk Analysis

Additional Control Measures

• Revised Risk Analysis

JSA Acknowledgement & Completion

Status of the JSA

Complete | Incomplete

Name and Signature of Conductor

If there are changes or if the JSA is incomplete, REVIEW the JSA and initiate the Review below.

Task Review

Were additional hazards identified when doing the task?

Yes | No

Were hazards and controls added to the JSA form?

Yes | No

• Has a copy been filed in the central filing system?

Yes | No

• Is a Work Permit required?

Yes | No

• Does a procedure need amending as a result of this JSA?

Yes | No

• Is there a training need because of the JSA?

Yes | No

Name and Signature of Reviewer

Name and Signature of Supervisor as Authorization

Click “Add Personnel” to enlist names & signatures of those who were involved with the JSA

Name and Signature

 

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