Job Safety Analysis – Sample JSEA Job Safety & Environmental Analysis Format Download

By | October 2, 2020

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.

JSA meaning in safety is job safety analysis, that sometimes replaces risk assessment forms. A job safety analysis form is part of safework method of statement SWMS.

You can use on your project without any hesitation, just include your company logo and project details.

The document given below covers all job safety analysis steps that a person needs doing jsa.

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:

 

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

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

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

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

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

IF IT’S NOT SAFE – DON’T DO IT THAT WAY!

RISK SCORE CALCULATOR

Use The Risk Score Calculator To Determine The Level Of Risk Of Each Hazard

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

 

Job Safety Analysis jsa format job hazard analysis

 

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 Statement

For

Control 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
   

 

 

 

 

   

 

 

 

 

   

 

 

 

 

 

   

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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