Job Safety Analysis Form printable pdf download

Job Safety Analysis Form

Event: ________________________

Effective Date: ____/____/_______ Number of Pages: ____ of ____

Department: __________________

Prepared By: _________________________________ Date: ____/____/_____

Reviewed By: _________________________________ Date: ____/____/_____

Approved By: _________________________________ Date: ____/____/_____

1. Equipment Operated:

______________________________________________________________________________

2. Environmental Conditions:

Inside Outside

Cold Heat

Wet Dust Vapors / Mist

Noise Vibration

Other_________________

3. Primary Job Functions & Position:

Lifting

Grasping

Pushing

Sitting

Reaching

Bending

Kneeling

Standing

Pulling

Squatting

Other_________________

4. Physical Demands:

(Continuously = 100% - 67%; Frequently = 66% - 34%; Occasionally = 33% - 1% Not Applicable = 0%)

___ Standing

___ Pulling

___ Kneeling

___ Walking

___ Climbing

___ Reaching

___ Sitting

___ Stooping

___Carrying (___ lbs. ___ distance)

___ Pushing

___ Bending

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Job Safety Analysis Form