Below is a template given for use on a construction project. Many organizations in place of risk assessment use job safety and environmental analysis which serves the same purpose.
At the end of this page we have given the link to download JSEA full template in editable word .doc format.
You can use on your project without any hesitation, just include your company logo and project details.
You will need to make changes as per different construction activities for which you are making the job safety analysis.
| Contractor or project logo |
Job Safety Environmental Analysis& (Risk Assessment) |
DATE:
JSEA No:
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| PRINCIPAL CONTRACTOR : | CONTRACTOR NAME: | |||||||||||||
| PROJECT: | ||||||||||||||
| LOCATION: | ||||||||||||||
| THIS JSEA IS TO BE REVIEWED ON: Weekly | ||||||||||||||
| JOB DESCRIPTION: | ||||||||||||||
| PLANNED HIGH RISK CONSTRUCTION ACTIVITY: | ||||||||||||||
| Work at Heights | Work on Roof | Entering Excavation | Using a Confined Space | |||||||||||
| Using a Hazardous Substance | Demolition Work | Asbestos Removal | Bodily Injury | |||||||||||
| EMERGENCY ACTION: | ||||||||||||||
| In the event of injury is a member of the work team First Aid Qualified? YES NO If yes, their Name? _______________________ | ||||||||||||||
| Point where an injured person may receive treatment: MINOR INJURY: Site Clinic SERIOUS INJURY: Site Clinic to | ||||||||||||||
| JSA STATEMENT DEVELOPED BY: | REVIEWED BY THE FOLLOWING PERSONNEL: | |||||||||||||
| No | Name | Signature | Position | Certificate No. |
No |
Name | Signature | Position | Date. | |||||
| 1 | 1 | |||||||||||||
| 2 | 2 | |||||||||||||
| 3 | 3 | |||||||||||||
Approved by: ________________________ Position: _________________________ JSEA Review for the month of:
Initial the box to confirm that you have carried out a daily review of this JSEA and a Pre Task safety briefing
| PPE REQUIREMENTS
Use |
PLANT, EQUIPMENT & TOOLS FOR JOB
Use |
TAGGING & SIGNS
Use |
PERMITS & INSTRUCTION
Use |
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| Safety Harness | Hearing Protection | Ladder | Fire Blanket | Men Working Above | MSDSs | |||||||||||||||||||
| Static Line | SCBA | Hand Tools | Excavator | Barrier Mesh | Instruction Manuals | |||||||||||||||||||
| Steel Capped Boots | Airline | Shovel | Winch | Flagging | Procedures (SPI) | |||||||||||||||||||
| Hard Hat | Air Purifying Respirator | Welding Machine | Extension Leads | Personal Locks | Work Instructions | |||||||||||||||||||
| Tinted Safety Glasses | Confined Space Harness | Compactor | Power Source | Personal Danger Tags | Hot Work Permit | |||||||||||||||||||
| Clear Safety Glasses | Gloves – PVC | Drill | Crane | Out of Service Tags | Isolation Permit | |||||||||||||||||||
| Mono goggles | Gloves – Hyflex (Nitrile) | Grinder | EWP | Information Tags | Excavation Permit | |||||||||||||||||||
| Face Shield | Gloves – Leather Riggers | Scaffold | Fans | Confined Space Permit | ||||||||||||||||||||
| Sun Screen | Chin Straps | Fire Extinguisher | Scissor Lift | |||||||||||||||||||||
| HAZARD PROMPT – “check ”. Identify the job hazards and assess the RISK personnel may be exposed to before safeguards are implemented: | ||||||||||||||||||||||||
| Electrical | N/A
Low Med High |
Vehicles | N/A
Low Med High |
Pressure | N/A
Low Med High |
Weather | N/A
Low Med High |
Radiation (Hot Work / Sun) | N/A
Low Med High |
Heat | N/A
Low Med High |
SMF or Asbestos | N/A
Low Med High |
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| Chemical | N/A
Low Med High |
Height | N/A
Low Med High |
Access | N/A
Low Med High |
Bacteria | N/A
Low Med High |
Rotating Equipment | N/A
Low Med High |
Dehydration | N/A
Low Med High |
Engulfment | N/A
Low Med High |
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| Tools | N/A
Low Med High |
Depth | N/A
Low Med High |
Vibration | N/A
Low Med High |
Dust | N/A
Low Med High |
Moving Equipment | N/A
Low Med High |
Hot / Cold Objects | N/A
Low Med High |
Lighting | N/A
Low Med High |
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| Gases | N/A
Low Med High |
Weight | N/A
Low Med High |
Noise | N/A
Low Med High |
Slip / Trip | N/A
Low Med High |
Lifting Equipment | N/A
Low Med High |
Overhead Hazards | N/A
Low Med High |
Manual Handling | N/A
Low Med High |
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IF IT’S NOT SAFE – DON’T DO IT THAT WAY!
RISK SCORE CALCULATORUse The Risk Score Calculator To Determine The Level Of Risk Of Each Hazard |
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| What would the
SEVERITY Of an occurrence be? |
What is the LIKELIHOOD of an occurrence? | Hierarchy of Controls | ||||
| Almost Certain | Very Likely | Likely | Unlikely | Very Unlikely | Can the hazard be Eliminated or removed from the work place? | |
| Disaster
Multiple Fatalities |
High 25 | High 20 | High 15 | Medium 10 | Medium 5 | Can the product or process be substituted for a less hazardous alternative? |
| Very Serious
Major Illness or Injury, disability |
High 20 | High 16 | High 12 | Medium 8 | Low 4 | Can the hazard be engineered away with guards or barriers? |
| Serious
Serious but non-permanent injury or ill health Work days lost |
High 15 | High 12 | Medium 9 | Medium 6 | Low 3 | Can Administration Controls be adopted
i.e. procedures, job rotation etc |
| Substantial
Medical attention needed. No work restrictions. |
Medium10 | Medium 8 | Medium 6 | Low 4 | Low 2 |
Can Personal Protective Equipment & Clothing be worn to safe guard against hazards? |
| Minor
Minor cuts & bruises or sickness |
Medium10 | Medium 4 | Low 3 | Low 2 | Low 1 | |
| No. | Job Step
What you do, NOT how you do it |
Hazard / Risk
Exposure What are the hazards of each job step? |
Risk Score |
Work Method StatementForControl of Hazard Exposures
What hazard controls will be used? Who will check the effectiveness of the controls? What checks will be undertaken? E.g. (Inspection & ongoing monitoring) |
New risk score
After controls applied |
Action By |
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Job Safety Analysis& (Risk assessment) |
DATE:
JSEA No:
|
SIGN ON SHEET
| Date | Name | Signature | Date | Name | Signature |
IF IT’S NOT SAFE – DON’T DO IT THAT WAY!
Download JSEA form template in editable doc format from below link:
JSEA Job Safety and Environmental Analysis Format SWMS 2 Oct 2020