JOB SAFETY ANALYSIS 

Rig/Facility: Date: Job Supervisor: Location:

 

Job:
Chemical Safety Data Sheet   Hazard ID Prompt Card
Permit to Work Required yes no Number: yes no Completed yes no
Reviewed
Stop Work Authority Manufacturer Instructions   Other References
yes no yes No
Discussed Reviewed
Will the job require planned stop work? yes no If yes, work pauses will be every __________ minutes Minimum number of people required: _________

Job Steps Hazards/Job Factors Barriers Persons Assigned

JSA Participants:
Name Position Signature Name Position Signature

Post Job Review: Is a new work instruction required? No Yes OIM Signature:

Stop Work Authority is the obligation of all employees to decline or stop work when they perceive a threat of danger to people, environment or asset.
FM-CO-RAC-801, 01-SEP-16