Job Safety Analysis Sample
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1
2TO BE UPDATED TO
REFLECT LATEST
LEGISLATIVE
SAMPLE JOB SAFETY
CHANGES
4/
ANALYSIS (JSA)
DOCUMENT
Documenting your chosen control measures helps show you have met your legal
obligations. Keep records to track what has been done and what is planned; effective
record-keeping can save time and money.
JSA number
Date
JSA team names
Clearance issuer
Task description
Removal of guarding from No. 1 and No. 2 conveyors for routine cleaning
Step
Step/task description
Potential hazard
Potential
Likelihood
Overall
Control measures
Revised
no.
consequence
ranking
risk
risk
ranking
rating
rating
1
> Job preparation
> Lock-out not put
Major
Likely
Extreme
> Permit/JSA/induction current
High
in place
> Induction of contractors and
> Nips and cuts
employees are current
> Residual gypsum
> Correct personal protective
equipment to be worn as site
procedure/clearance certificate
2
> Isolate equipment as per
> Lack of
Major
Moderate
Extreme
> Inform affected parties before
High
isolation procedure
communication
commencing isolations
> No. 1 conveyor lock and
> Nips and cuts
> Be aware of pinch points
tag off
> Slips, trips
> Be aware of slip, trip hazards
> No. 2 conveyor lock
> Follow isolation procedures
and tag off
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Parent category: Business