Job Safety Analysis Worksheet

This Job Safety Analysis (JSA) form is completed to critically examine a contracted work task and where required to alter that task to ensure that the risk of personal or property
damage is minimized. Contractor JSA or Safe Work Method Statement (SWMS) templates can also be accepted.
This JSA must be completed prior to commencement of the following tasks to confirm acceptable levels of risk control:

 working from height  working on or near live electricity

 using hazardous substances and
 Isolating fire system  excavation work
dangerous goods  demolition or structural alterations
 working with installed  entry to confined spaces
 asbestos removal or disturbance  Work adjacent to roadways
plant
Name of
Name of Contractor/s
Company

Work order
Date Project number
number

Reviewed by
JSA prepared by
UoW manager

Description of the job:

Items of plant, tools and equipment to skills/competencies/licenses

Any relevant safe work procedures Protective equipment required:
be used required for safe job performance

Overalls Footwear

Hearing Sunscreen
protection
Eye protection
Hard hat
Cut proof trouser
Gloves
Other
High visibility
vests

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Job Safety Analysis Worksheet

Potential Who is responsible for

Process task Risks Risk control measures
hazards controlling the risk?

Against each For each

List the task required
task list the hazard describe Describe the intended risk control measures. Apply the Hierarchy of
to perform the job in List the person responsible for
hazard(s) that the level of risk Control: elimination, substitution, engineering controls, administrative
the sequence they controlling each risk.
could cause that may be controls and protective equipment.
are carried out.
injury. present.

Comments:

UoW Manager / Manager / Supervisor Name Signature Date

Supervisor
Endorsement

This endorsement is to ensure that the manager is aware of the intended work of the contractor. It is not necessary for the manager to have a specific knowledge
of work task or controls. Refer to line manager or H&S Consultant for further advice if required.

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