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Free Job Safety Analysis Form

A sample Job Safety Analysis template that you can use to review the safety aspects of your job site.






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  3. Riverside House
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Free Sample Job Safety Analysis Form

Word   PDF  

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

5. Potential Hazards: Controlled By

Impact
PPE Procedure Training Guards

Chemical Contact
PPE Procedure Training Guards

Caught on or Between
PPE Procedure Training Guards

Fall or Slip
PPE Procedure Training Guards

Over Exertion
PPE Procedure Training Guards

Cumulative Trauma
PPE Procedure Training Guards

Other
PPE Procedure Training Guards

6. List of Specific Hazards: ___________________________________

7. List of Chemicals:___________________________________________

8. PPE:

Eye _______________ Face _______________ Head _______________

Clothing ______________ Hand _______________ Other_______________

Foot _______________ Respiratory ___________ Other_______________

9. Procedure Details:










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Continuous Improvement

Corrective Action
Workflow Chart
Job Safety Analysis
Risk Analysis Form
Employee Time Study Flow Sheet
Process Improvement Plan
Root Cause Failure Analysis Form

Reporting Accidents
Employee Incident Report
Employee Accident Report
Accident Claim Letter
Accident Claim Worksheet
Injury Report Form
Employee Accident Log
Fire Drill Report



End Of Employment
Employee Termination
Two Week Notice Letter
Resignation Letter
Farewell Letter For Retirement
COBRA Notification
Employment Verification

Exit Interview
Employee Exit Interview
Exit Interview Questions






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