Job safety analysis (jsa) form checklist
Post training jsa form
What does this form include?
This form contains 31 sections:
work order number
task activity
date Date
Site number/Name
name of contractor/Subcontractor
check applicable anticipated or potential hazards
- Demolition
- Underground tank removal/Disposable/High vapors
- Activities in or near traffic areas
- Concrete cutting or coring
- Mobile heavy equipment activity (excavators, dump trucks, vacuum and hydovac trucks)
- Pile driving / shoring
- Work affecting integrity of critical controls
critical procedures: where work involves any of the following hazards must be incorporated into JSA
- Work at heights above 1.5m
- Confined space entry (includes tank cleaning)
- Electrical/Mechanical lockout (live, isolation, lock out / tag out
- Heavy equiptment lifting (cranes, boom trucks, excavators)
- Drilling borehole / excavations (Sub-surface clearance, locates)
- Entry into excavations/Trenches > 1.2 m (4ft) deep
- Hot work (in potentially explosive atmosphere)
1. sequence of basic job Step in order
1.potential hazards. (Ex. underground services, hazard zone etc.)
1.safety controls to reduce or eliminate hazard
2. sequence of basic job Step in order
2. potential hazards. (Ex. underground services, hazard zone etc.)
2. safety controls to reduce or eliminate hazard
3. sequence of basic job Step in order
3. potential hazards. (Ex. underground services, hazard zone etc.)
3.safety controls to reduce or eliminate hazard
4. sequence of basic job Step in order
4. potential hazards. (Ex. underground services, hazard zone etc.)
4.safety controls to reduce or eliminate hazard
5. sequence of basic job Step in order
5. potential hazards. (Ex. underground services, hazard zone etc.)
5.safety controls to reduce or eliminate hazard
tools / Equipment ( list of tools and equipment and their storage on site, if relevant to safety
additional PPE ( minimum requirement: safety boots, hard hat, visi-vest, glasses, gloves)
- Eye protection
- Hearing protection
- Fall protection
- Rubber footwear and gloves if in a damp area
- Portable gas monitor
Other (fire retardant coveralls, breathing apparatus, etc) specify :
outside authorities
Add signature
prepared by
person carrying out work
JSA approved retailer/Sales associate signature
Use this template