Job Safety Analysis (JSA)
Job Name: _________________________ Department/Area: ______________________________ Date: _____________
Name of person conducting JSA: _________________________
Required PPE:
Sequence of Job Steps
Required Tools & Equipment
Potential Hazards
Materials Used:
Controls to be implemented
Employees performing and affected by job tasks:
Employee Printed Name
Employee Signature
Employee Printed Name
1.
11.
2.
12.
3.
13.
4.
14
5.
15.
6.
16.
7.
17.
8.
18.
9.
19.
10.
20.
Signature of Preparer: ________________________
Employee Signature
Signature of Safety Manager: ________________________