Job Safety Analysis Form

Download a blank fillable Job Safety Analysis Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Job Safety Analysis Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Print Form
Job Safety Analysis Form 
Unit Operations Laboratory – Cain Department of Chemical Engineering – Louisiana State University 
 
Experiment 
_______________________________ 
JSA Authors 
__________________________________ 
Date 
_______________________________ 
Instructor 
__________________________________ 
 
Experimental Program Description 
__________________________________________________________________________________________________ 
 
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 
________________________________________________________________________ 
 
Fire/Flammability 
________________________________________________________________________ 
 
Reactivity 
________________________________________________________________________ 
 
Pressure Hazard 
________________________________________________________________________ 
 
Temperature Hazard 
________________________________________________________________________ 
 
Hot Surfaces (>150°F) 
________________________________________________________________________ 
 
Electrical Hazard 
________________________________________________________________________ 
 
Mechanical Hazard 
________________________________________________________________________ 
 
Biohazard 
________________________________________________________________________ 
 
Laser/Ionizing Radiation 
________________________________________________________________________ 
 
Other  _____________ 
________________________________________________________________________ 
 
Other  _____________ 
________________________________________________________________________ 
 
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 
 
PEL 
TLV 
________________________ ____  ____  ____  ________   ________  _______________________________________ 
________________________ ____  ____  ____  ________   ________  _______________________________________ 
________________________ ____  ____  ____  ________   ________  _______________________________________ 
________________________ ____  ____  ____  ________   ________  _______________________________________ 
________________________ ____  ____  ____  ________   ________  _______________________________________ 
________________________ ____  ____  ____  ________   ________  _______________________________________ 
 
Emergency Shutdown – Minimum required procedure to leave experiment in a safe condition prior to evacuation. 
__________________________________________________________________________________________________ 
Hjtoups: Based in large part on components of Michigan Technology University’s Job Safety Assessment Form 
June 07 

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go