Jsa checklist
Hazard assessment and analysis worksheet
What does this form include?
This form contains 17 sections:
Task
Position/Occupation
Company
Location
Supervisor Name and Title
Worker(s) Name and Title
Frequency Rating (3-Daily/Frequently, 2-Monthly/Occasionally, 1-Quarterly/Rarely)Severity Rating (3-F
Task Analysed
Task Steps-Activities
Photo Support
Existing or Potential Hazards
Health and/or Safety
Task Analysis
- Frequency
- Severity
- Probability
Priority Rating
Current Hazard Control
Hazard Control Required or Improvement Recommended
Assigned to
Use this template