JOB SAFETY ANALYSIS (JSA) FORM

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Company

Please Tell Us The Name Of The Staffing Company You Work For *

1—Job/Task

Date *

What is the current job and/or task that you perform at work? *

Employee Name

2—Work Location

What is the current address were you work? Do you work at more then one locations? *

3—New or Revised

New—Is this the first time filling out the JSA Form for current job/task

Revised—Job/task has changed and JSA is being revised and updated

4—What Is The Most Hazardous Part Of This Job And What Are You Going To Do To Control The Hazard?

In your option what is the most hazardous or dangerous part of your job? *

5—Are You Properly Trained To Complete This Task?

Were you provided with any training before you started your job? *

6—Mentor

Who trained you? *

7—What Do You Need To Ensure This Job Is Completed Incident And Injury Free?

Do you need any safety equipment to make sure your job is done safely so you don’t get hurt? *

8—What Conditions, Job Changes Or Distractions Could Call For The Need To Stop Work Production?

Do you feel there are any dangers at your job were you could get hurt? Are you ever asked to do a new job that your not trained to do? *

9—Sequence of Job Steps

Tell me briefly what you do on your job? *

10—Potential Hazards

If you were to get hurt doing your job what do you think could happen based on what you do? *

11—Recommended Action or Procedure

What to do you think you could do not to get injured? *

12—Additional Personal Protective Equipment

Please check what personal safety equipment you use. *

Face Shield Proper Gloves Proper Boots Fall Protection Hearing Protection Respiratory Protection Chemical Goggles None

13—Chemical Hazards

Do you work with and chemicals? Yes or No if YES please tell us what checmials. *

14—Hazardous Energy Equipment

Are there any heavy equipment hazards? *

LO/TO LO/TO Devices In Place Electrical Hydraulic Pneumatic Mechanical None

15—Environmental Conditions

Is it to Hot or Cold were you work? *

Hot Cold None

16—Tools And Equipment

Do you use any tools on the job? And were you trained to use these tools? *

Pre-Use Inspection Complete Trained In Use Of Tool/Equipment List Tools Being Used None

Examine Each Step Carefully To Find And Identify Hazards Or Potential Dangers That Could Lead To Injury,
Illness Or Damage, Consider The Following:

17—Chemical Hazards

Are you exposed to any chemical that you could breath in, Touch you skin, absorbe thru your skin, inject or swallow? *

Inhalation Skin Contact Injection Absorption Ingestion None

18—Biological Hazards

Are you ever exposed to blood, mold, plants, insects, or animals *

Bloodbome Pathogens Mold Plant/Insect/Animal None

19—Physical Hazards

Do you think there are any physical hazards? *

Electrical Fire/Explosion Noise Radiation Slips/Falls None

20—Ergonomic Hazards

Does your job have any unusual conditions? *

Repetition Forceful Exertion Vibration Awkward Posture None

21—Employee Signature

Employee Name *

Signature *

Date *

I agree that the signature will be the digital representation of my signature for this JSA analysis form. The same as a pen and paper signature.

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Questions or concerns? Please
contact the Safety Department

Tami V., or Ashley L.

JOB SAFETY ANALYSIS (JSA) FORM

Questions or concerns? Pleasecontact the Safety Department

Tami V., or Ashley L.

Safety Coordinator

Phone

Email

Questions or concerns? Please
contact the Safety Department