Jsa checklist
Job safety analysis
What does this form include?
This form contains 21 sections:
Safe Work Method Statement -This document is to be used by property management personnel or contracto
Company Name
Company Address Address
General Information
Name of Responsible Person
Commencement Date Date
Signature
Description of the work?
Specific work location? Address
What are the hazards associated with the work?
Take photo's of any major hazards
Select the general control measures for the task here
List all site specific control measures here?
Select the plant and equipment required for the task?
Take pictures of certified plant labels here
Select the personal protective equipment (PPE) required for the task?
Select the permits required for the task here?
Add photo's to show how the area/task has been made safe before work commences
I hereby confirm that I have been briefed on the above information and will comply with all the contr
Person(s) undertaking the work please sign here
Date Date
Use this template