HSE Job Safety Analysis Form

Segment: Site: Location of Work: Please 

Google MCKINLEY One Campus Place Tower A Campus Ave. Mckinley Hill Taguig City Planned (Routine) Reactive (Non-Routine)
Prepared by RA Team Leader: Job Position: Signature: Date Completed: Next Review Date: JSA Reference No.
Raul Abarico Technical Service Supervisor April 08, 2024
Team Member: Job Position: Review & Approved by Site Manager / Lead:
Raul Abarico Technical Service Supervisor
Jaymark Dela Torre Service Technician Name: Job Position: Signature:
Rene Gustilo Technician
Prince Joshua Ardenia Technician Rustin Derick Yusi Sr. Technical Supervisor
Mark Vincent Vito Technician
Robert Austin Dela Cruz Technician
Joelan Española Technician
Clarence Jay Ganir Engineer

Scope of work (Job task/activity): Global Life Safety Hazard

Yes No
Program 
PREVENTIVE MAINTENCE SERVICES FOR VARIOUS KITCHEN EQUIPMENT:
Life Safety Hazard Activity?
Wipe down Shelves & Interiors
Clean Flat top Griddle Plate or Char broiler Grates Completed specific Safety nets
Sanitize Equipment card?
Check AC Current of Equipment
Aligning Mechanical Parts
Dismantling and Installation of Spare Parts
Gas line leak testing
Test and Observe Equipment after Repair/PM.
Charging of Refrigerant
Repair Water /Gas Leaks
Descaling of Boiler and Heaters
Clean Condenser and Evaporator Coils
Clean Fan Blades
Check Spare Parts Condition
Check & Replace water Filtration Cartridges
Empty and Clean Grease cup or waste drawer All YES to proceed with work?
Check and Clean Air Filters
Check Door and Hinges Alignment
Wipe Down Door Gaskets with approved cleaner
Delime the steam Generator
Inspect and Clean Drain Lines
Inspect & Calibrate Thermostat
Test Water Temperature and Pressure of Dishwashing machine
Test Equipment before PMS
Check and Lubricate all Mechanical Moving Parts
Dismantling of Panel Covers

Based on the above identified Scope of Work, please  all relevant boxes below. Do another final check after completing the JSA & Safe System of Work.
ALL KNOWN HAZARDS  where applicable

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 Manual Slip/ Trip / Work Noise/ Electric Vehicles Working Fire / Biological Fragile Cuts Cold/ Hot Hot Falling Gases Hazardous Radiation Others (Pls specify)
Handling Fall Area / Dust Shock at Height Explosion Roof Temps Surfaces Objects Chemicals/
Condition (Outdoor) Materials
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PERSONS AT RISK OF HARM  PTW REQUIRED FOR WORK ACTIVITY 

Sodexo employees Master Permit Hot Work Permit

Client Access to areas containing Asbestos Mechanical Systems Permit

Contractors Confined Space Permit Pressure Systems Permit

Visitors Electrical Systems Permit Working at Height Permit

Public Excavation Limitation of Access Permit

Others (Please Specify): Specialist Systems Isolation / Monitoring (e.g. Fire / Data Centre) Transfer of System Control Permit

Any others (Please Specify):

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 Identify Evaluate Manage

Final
Risk Rating
Hazards associated Risk Rating
Step Job step details Responsbile person
(Identify the hazards that could hurt a person, asset or All Control measure(s)
(Detail the task by breaking the job down into steps and in the (Identify who is responsible to ensure each
no. sequence they are carried out)
impact the environment. What harm could occur as a result (What controls must be in place to prevent harm?)
control is implemented)
of exposure to the hazard?)
S L R S L R

1 Sanitize Equipment - May suffer to chemical exposure / Covid 2 2 4 - Wear a Face Mask 2 1 2 Raul Abarico (Technical Lead)
Infection, Slip from oily / Tripping from - Frequent hand washing with soap and sanitizing /
obstruction Physical distancing 1M apart
Test Equipment before PMS
- Slip, Trips and Fall Hazard - Proper Housekeeping / Use of Proper PPE (Safety
- Skin Irritation Shoes)

2 Aligned Door and Hinges - Slip, Trip and Fall Hazard 2 2 4 - Wear Face Mask 2 1 2 Raul Abarico (Technical Lead)
- Ergonomic Injuries - Proper inspection of materials & working conditions of
Lubricate all Mechanical Moving parts - Poor Illumination tools to be used
- Hand pinching injury. - Proper Handling of Tools and Materials
- Use of proper PPE (Safety Shoes)
- Use proper lifting techniques, use trolley if available
- Proper Housekeeping
- Beware of pinch points
- Use proper light to ensure sufficient illumination in
work area
3 Check Spare Parts Condition - Slip, Trip and Fall Hazard 2 3 6 - Wear Face Mask 2 2 4 Raul Abarico (Technical Lead)
- Ergonomic Injuries - Proper inspection of materials & working conditions of
- Poor Illumination tools to be used
- Hand pinching injury. - Proper Handling of Tools and Materials
- Use of proper PPE (Safety Shoes)
- Use proper lifting techniques, use trolley if available
- Proper Housekeeping
- Beware of pinch points
- Use proper light to ensure sufficient illumination in
work area
4 Test the Water Temperature and Pressure of the - Slip, Trip and Fall Hazard 3 3 9 - Wear Face Mask 3 2 6 Raul Abarico (Technical Lead)
Dishwashing machine - Ergonomic Injuries - Proper inspection of materials & working conditions of
- Poor Illumination tools to be used
Replace water filtration cartridges - Hand pinching injury. - Proper Handling of Tools and Materials
- Use of proper PPE (Safety Shoes)
- Use proper lifting techniques, use trolley if available
- Proper Housekeeping
- Beware of pinch points
- Use proper light to ensure sufficient illumination in
work area

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 Identify Evaluate Manage

Final
Risk Rating
Hazards associated Risk Rating
Step Job step details Responsbile person
(Identify the hazards that could hurt a person, asset or All Control measure(s)
(Detail the task by breaking the job down into steps and in the (Identify who is responsible to ensure each
no. sequence they are carried out)
impact the environment. What harm could occur as a result (What controls must be in place to prevent harm?)
control is implemented)
of exposure to the hazard?)
S L R S L R

5 Delime the steam generator - Slip, Trip and Fall Hazard 2 2 4 - Wear Face Mask 2 1 2 Raul Abarico (Technical Lead)
- Ergonomic Injuries - Proper inspection of materials & working conditions of
Dismantling and Installation of Spare Parts - Poor Illumination tools to be used
- Hand pinching injury. - Proper Handling of Tools and Materials
- Use of proper PPE (Safety Shoes)
- Use proper lifting techniques, use trolley if available
- Proper Housekeeping
- Beware of pinch points
- Use proper light to ensure sufficient illumination in
work area
6 Test and Observe Equipment after Repair/Install - Slip, Trip and Fall Hazard 2 2 4 - Wear Face Mask 2 1 2 Raul Abarico (Technical Lead)
- Ergonomic Injuries - Proper inspection of materials & working conditions of
- Poor Illumination tools to be used
- Hand pinching injury. - Proper Handling of Tools and Materials
- Use of proper PPE (Safety Shoes)
- Use proper lifting techniques, use trolley if available
- Proper Housekeeping
- Beware of pinch points
- Use proper light to ensure sufficient illumination in
work area

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 Identify Evaluate Manage

Final
Risk Rating
Hazards associated Risk Rating
Step Job step details Responsbile person
(Identify the hazards that could hurt a person, asset or All Control measure(s)
(Detail the task by breaking the job down into steps and in the (Identify who is responsible to ensure each
no. sequence they are carried out)
impact the environment. What harm could occur as a result (What controls must be in place to prevent harm?)
control is implemented)
of exposure to the hazard?)
S L R S L R

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 Existing SSW available?  State SSW Reference no:
SAFE SYSTEM OF WORK (SSW) Yes
No (Proceed to below)

Note: Relevant & existing Safe Systems of Work (SSW) is to be cross-reference/attached and noted in the detailed JSA form. If not available, complete this Safe System of Work.

Before starting the work task,

 1. DO I KNOW HOW TO DO THE JOB?
Specialist Training / Competency required to complete task:

 2. DO I HAVE THE RIGHT EQUIPMENT?

Specific Equipment / Tool required to complete task:
Combination Wrench
- Vise GRIP
- Fliers
- Precision Screwdriver
- Manifold Pressure Gauge HSP
- Manifold Pressure Gauge LSP
- Manifold Hose Red Yellow Blue
- Philip Screw - Adjustable Wrench
- Allen Screw
- Water Pressure Washer
- Pushcart Trolley
- Plastic Bucket Pail
- vacuum
- mobile phone

Specific Personal Protective Equipment (PPE) required to complete task.  where applicable

Air Fed Face Goggles Safety Ear Safety Anti-Slip Hard Bump Hair Net/ Coverall Hi-Viz Apron White/ Half Respirator Dust Fume/ Harness / Cut-Resistant Protective
Helmet Visor Glasses Defender Boots Covered Hat Cap Chef Hat Vest Chef Coat Respirator Mask Vapour Lanyards Gloves Gloves
Shoes Mask
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  3. IS MY ENVIRONMENT SAFE?
Identify and state what surrounding environment factor(s) will prevent the work activity from being carried out safely and (ii) what action(s) are required to make it safe
If any new hazard(s) are found, this must be included and evaluated in the JSA form.
What weather condition(s) will prevent the work activity being carried out safely and/or may introduce new hazard(s)?
1.
No Yes with comments:

What simultaneous operational work(s) performed in the same work area will prevent the work activity being carried out safely and/or may introduce new hazard(s)?
2.
No Yes with comments:

What other condition(s) are there in the surrounding work environment that will prevent the work activity from being carried out safely and may introduce any new hazard(s)?
3. (E.g. Poor housekeeping, uneven ground, wet flooring, poor lighting, pressurized pipe, equipment obstruction, high temperature, gas emission)
No Yes with comments:

Identify Safe System of Work (SSW) to carry out during this work activity: Note: Ensure these already included in the JSA job steps above Page 2 onwards

ACKNOWLEDGEMENT

EMPLOYEE SIGNATURES
I have read and understood the content of this JSA.
I fully understand the activity outlines above and the risk control measures that I must implement to perform my work safely. I have received sufficient information, instruction and training so as to enable
me to conduct this activity with the minimum risk to myself.
EMPLOYEE NAME SIGNATURE DATE EMPLOYEE NAME SIGNATURE DATE

Raul Abarico April 08, 2024 Mark Vincent Vito April 08,2024

EMPLOYEE NAME SIGNATURE DATE EMPLOYEE NAME SIGNATURE DATE

Jaymark Dela Torre April 08, 2024 Robert Austin Dela Cruz April 08,2024
EMPLOYEE NAME SIGNATURE DATE EMPLOYEE NAME SIGNATURE DATE

Prince Joshua Ardenia April 08, 2024 Clarence Jay Ganir April 08,2024
EMPLOYEE NAME SIGNATURE DATE EMPLOYEE NAME SIGNATURE DATE

Rene Gustilo April 08, 2024

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EMPLOYEE NAME SIGNATURE DATE EMPLOYEE NAME SIGNATURE DATE

Joelan Española April 08, 2024

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