Job Safety Analysis Form
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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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