Job Safety Analysis Template 3
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Job Safety Analysis Worksheet
Company name:

Date:

Site name:

Permit to work requirement:

Contractor:

Approved by:

JSA No.
Yes

No

Activity:

Activity

Hazards

Risk control measures

Who is responsible?

List the tasks required to perform the activity in the
sequence they are carried out.

Against each task list the hazards that could cause injury
when the task is performed.

List the control measures required to eliminate or minimise
the risk of injury arising from the identified hazard.

Write the name of the person responsible (supervisor or
above) to implement the control measure identified.

Remember: Each JSA must be site specific.
Include all workers in the development of this JSA.
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