JOB TITLE: DATE:

NEW
JOB SAFETY ANALYSIS
REVISI

COMPANY/ORGANIZATION: TITLE OF PERSON WHO DOES JOB SUPERVISOR: ANALIZED BY:

PLANT/LOCATION: DEPARTMENT: REVIEWED BY: APPROVED BY:

PROTECTIVE EQUIPMENT AND SYSTEM REQUIRED TO PERFORM THIS JOB

(Alat Pelindung Diri yang diperlukan untuk melakukan pekerjaan)
Hard Hat Leather Gloves Goggles Permit To Work Req.
Safety Shoes Work Vest/ Life Jacket Barricade Other ………….
Safety Glasses Safety Harness Fire Extinguisher
Work Gloves Face Shield Lock Out/ Tag Out
Risk Factor (Severity x Residual
Sequences of Potential hazards Probability) Recommended to eliminate or reduce Risk (Severity x
basic job steps & potential hazards and risks Probability)
Bahaya Potensial Risk Class. &Risk Class.
Tahapan
Pekerjaan S P RC S P RC

1 of ……
2 of ……
S : Severity / Keparahan
P : Probability / Kemungkinan
RC : Risk Class / Tingkat Risiko

Severity / Keparahan
Negligible/ Dapat Moderate / Keparahan Critical / Keparahan Catastrophic / Berakibat
Diabaikan Sedang Kritis Bencana

Probability / Kemungkinan 1 2 3 4

Seldom/ Jarang Terjadi 1 1 2 3 4

Occasional / Kadang Terjadi2 2 4 6 8

Likely / Sering Terjadi 3 3 6 9 12

Frequent / Sangat Sering 4 4 8 12 16

Risk Class:

Extremely High

High

Medium

Low

3 of ……