JOB SAFETY ANALYSIS (JSA) FORM – Order Number 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 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 New—Is this the first time filling out the JSA Form for current job/task Or Revised—Job/task has changed and JSA is being revised and updated 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. * Yes No 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. 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. BACK Questions or concerns? Pleasecontact the Safety Department AJ Martinson Safety Specialist OFFICE (714) 796-9110Dial 7 EXT 8118 FAX (714) 276-0129 CELL (657) 341-9804 EMAIL [email protected] Ashley L. Safety Coordinator PHONE (714) 796-9110 EMAIL [email protected]