JOB SAFETY ANALYSIS (JSA)
Overall Risk Assessment Code (RAC) (Use highest code)
Risk Assessment Code (RAC) Matrix
Probability
Severity
Frequent
Likely
Occasional Seldom
E
E
H
H
Catastrophic
M
E
H
H
Critical
M
M
L
H
Marginal
M
L
L
L
Negligible
PRE-TASK PLAN and JOB SAFETY
ANALYSIS
Work Plan Description
Project Name
Project Number
Foreman
Date
Unlikely
M
L
L
L
Step 1: Review each “Hazard” with identified safety “Controls” and determine RAC (See above)
“Probability” is the likelihood to cause an incident, near miss, or accident and
RAC Chart
identified as: Frequent, Likely, Occasional, Seldom or Unlikely.
“Severity” is the outcome/degree if an incident, near miss, or accident did occur
E = Extremely High Risk
and identified as: Catastrophic, Critical, Marginal, or Negligible
H = High Risk
Notes:
Step 2: Identify the RAC (Probability/Severity) as E, H, M, or L for each “Hazard”
on JHA. Annotate the overall highest RAC at the top of JHA.
TASKS
HAZARDS
CORRECTIVE MEASURES
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
 Work in Energized Equipment?
M = Moderate Risk
L = Low Risk
RAC
If Yes, Electrical Hot Work Permit is required.
PPE
TOOLS
Hard Hat
Long Pants
Safety Toed Boots
Balaclava (Hood)
Gloves (Avail. 100%, appropriate to work activity)
Safety Glasses (Z87.1) at all times
CAL Suit rating:
Volt Rated Gloves
Elec. Drill
Ext. Cord
Hand Tools
Volt Rated Tools
Injured Today? CHECK Y o r N
EQUIPMENT
Step Ladder
Extension Ladder
Power Actuated Tool
Hand Pipe Bender
Power Pipe Bender
Generator
Manlift
Crew Names / Signatures
Print
Signature
Crew Names / Signatures
Print
Signature
Print
Signature
Print
Signature
Print
Signature
Print
Signature
Supervisory Review Signature:
Wire Puller Machine
Light Plant
Scissor Lift
Forklift
Injured Today? CHECK Y o r N
Date:
JHA Rev. 9.3.2014
Notes or carry over from front page:
Safety Suggestions, Concerns or Needs:
Equipment, materials or tool needs:
How can todays tasks be performed safer or more efficiently: