JOB SAFETY ANALYSIS Page 1 of 5

Date: Facility: / Area on Facility:
Describe Job Being Analyzed: / Job Safety Analysis Conducted By (name and company):
Permit to Work Required / NO / YES / Description / SDS Sheet Reviewed / NO / YES
Hazard Assessment / NO / YES / Description / Chemical Name
Work Instruction Reviewed / NO / YES / Description / Other References / NO / YES
Hazard Checklist: / Permits /Procedures Required: / PPE Checklist:
☐Fire/Hotwork
☐Open Holes
☐Dropped Objects
☐Simultaneous
Operations
☐Pinch Points
☐Cranes/Rigging
☐Stored Energy
Weather – ☐Seas / ☐Chemicals
☐Spills/Leaks
☐Working At Heights
☐Noise
☐Pressure
☐Fumes
☐Vibration
☐Electricity
☐Wind / ☐Weather
☐Lighting
☐Confined Space
☐Moving Machinery
☐Insect/Animal Bites
☐Tools/Equipment
☐Rotating Equipment
☐Other: ______
☐Rain / ☐Hot Work Permit
☐Cold Work Permit
☐Confined Space Entry Permit
☐Energy Isolation/LOTO Permit
☐Open Process Piping Permit
☐Crane Operation and Rigging
☐Fall Protection Procedures
☐Open Hole Barricade
☐Weather Related Procedures
☐Others: / ☐Hard Hats
☐Safety Glasses
☐Face Shield
☐Goggles
☐Steel Toed Boots
☐Gloves
☐Hearing Protection
☐Personal Flotation Device
☐Fall Protection
☐Respirator
☐Other:

List all Personnel Involved with Job (Please Print Name & Sign):

Name:

/

Job Title:

/

Company:

/

Name:

/

Job Title:

/

Company:

SEQUENCE OF JOB STEPS

/

POTENTIAL HAZARDS OF EACH STEP

/

RECOMMENDED HAZARD CONTROL

/

RESPONSIBLE PARTY

(Name of Person)
***EVERYONE HAS STOP WORK AUTHORITY***
(If Stop Work is initiated the JSA must be reviewed and/or revised. Once revised will require resigning by all task members)

(Note: Use another form and number accordingly if additional space is needed for names or job sequence steps)

Was the Stop Work Policy explained to everyone? / NO / YES
Was Ultimate Work Authority explained to everyone? / NO / YES
Name of the Ultimate Work Authority designee
OR Ultimate Work Authority title/position
In the event that a High Risk Stop Work Authority is used, prior to commencing work the Ultimate Work Authority signature is required.
Printed Name
Signature
Date
DWRAPS #

Approval Signatures:

Immediate Supervisor of Job/Task: Name (print): Company: .

Signature: Date: .

Person in Charge (PIC) or Consultant: Name (print): Company: .

Signature: ______Date: .

JSA Risk Assessment Prompts For Reference
JOB ELEMENTS / HAZARDS
(all uncontrolled sources of energy) / CONTROLS
Air Tugger / Asphyxiation / Absorbent Material
Electrical Work / Back Strain/Injury/Manual Handling / Assistance (Extra Man)
Explosives / Burns / Barrier Cream
Giving Signals (verbal, signs or radios) / Caught Between / Barriers Around and Below Worksite
Hand Tools / Corrosive/Oxidizing / Be Safe By Position
High Pressure Washdown / Crushing/Trapping / Breathing Apparatus
Lifting Loads / Cuts/Abrasions / Communications/Radio
Man Riding Operations / Dropped Objects / Correct Hand Placement
Manual Handling / Dropped Objects Through Gratings / Correct Tools
Mechanical / Drowning / SDS Assessment Required
Working Outside Hand Rails / Entanglement / Dust Mask/Respirator
Painting / Equipment Failure / Ear Protection
Power Tools / Eye Injury / Fall Arrestor
Pushing/Pulling / Falling From Heights / Fire Extinguisher/Watchman
Rigging / Fire/Explosion/Ignition / Formal Risk Assessment Required
Rotating Equipment / Flying/Falling Materials / Gas Detection
Scaffolding / Fumes/Vapors / Gloves/Gauntlets/Special Gloves
Slinging / High Noise/Vibration / Goggles/Face Shield
Stacking/Storing / Inexperienced Personnel / Hand Rails
Supervising Activities / Pinch Point (Hands and Feet) / Harness
Welding / Poisoning / Housekeeping First
Working On Gratings / Poor Lighting/Visibility / Isolation
Portable Electrical Equipment / Mentor
Portable Air Tools / PA Announcement
Shock/Electrical Energy / Permit To Work
Swinging Loads / Safe Storage of Tools
Skin Irritation From Chemical / Scaffolding
Slipping / Slicker Protective Suit
Struck By / Slings and Shackles (Color)
Temperature Extremes / Tag Lines
Toxic Gases/Vapors / Tie Off Tools
Tripping / Training
Weather / Whip Checks
Working in Confined Space