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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.




Free Sample Job Safety Analysis Form



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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