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Job Safety Analysis Form
Unit Operations Laboratory – Cain Department of Chemical Engineering – Louisiana State University
Experiment
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JSA Authors
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Date
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Instructor
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Experimental Program Description
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Personal Protective Equipment (PPE) – Check all additional PPE to be worn during any part of the experimental work.
Lab Coat
Chemical Goggles
Particle Mask
Chemical‐Resistant Gloves
Full Face Shield
Cartridge Respirator
Chemical Apron
Other _________________
Other
_________________
Hazards Summary – Check all the general hazards that are likely to be encountered during this experimental program
and list the major sources of and exposure means for each hazard, and the precaution to take to avoid exposure.
Hazard
Major Source of and Exposure to Hazard – Precaution to Take
Toxicity
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Fire/Flammability
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Reactivity
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Pressure Hazard
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Temperature Hazard
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Hot Surfaces (>150°F)
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Electrical Hazard
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Mechanical Hazard
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Biohazard
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Laser/Ionizing Radiation
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Other _____________
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Other _____________
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Available Safety Equipment – Provide the location of each item shown below. If not available, type NA in the field.
Item
Location
Item
Location
Fire Extinguisher ________________________
Eyewash
_____________________________________
Safety Shower
________________________
Telephone
_____________________________________
First Aid Kit
________________________
Other ___________ _____________________________________
Chemical Information – Fill in as much of the data below as possible. List all chemicals used or produced.
Chemical Name
NFPA Ratings
Airborne Exposure
Disposal Method
H
F
R
PEL
TLV
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Emergency Shutdown – Minimum required procedure to leave experiment in a safe condition prior to evacuation.
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Hjtoups: Based in large part on components of Michigan Technology University’s Job Safety Assessment Form
June 07