JSA_Form

Document Sample
JSA_Form Powered By Docstoc
					Job Safety Analysis Form
Task:
Effect Date:                                   # of Pages 1 of 1
Department:




Prepared By:                                Reviewed By:                                Approved By:
        Date:                                        Date:                                         Date:
1. Equipment Operated
2. Environmental Conditions
  Inside         Outside             Cold         Heat           Dust          Vapors/ Mist                Noise    Vibration

  Other

4. Primary Job Functions & Position
   Lifting     Grasping          Pushing        Sitting        Reaching             Bending        Kneeling        Standing

   Pulling     Squatting         Other

4. Physical Demands                         Continuously (C) 67-100%                    Occasionally (O) 1-33%
                                            Frequently (F) 34-66%                       Not Application (N) 0%
 Standing                  Walking                Sitting                 Pushing                Pulling

 Climbing             Stooping                 Bending              Kneeling                  Reaching

 Carrying
5. Potential Hazards
                                               PPE           Procedure          Training            Guards         Rest/ Break

                                               PPE           Procedure          Training            Guards         Rest/ Break

                                               PPE           Procedure          Training           Guards          Rest/ Break

                                               PPE           Procedure          Training            Guards         Rest/ Break

                                               PPE           Procedure          Training            Guards         Rest/ Break

                                               PPE           Procedure          Training            Guards         Rest/ Break

                                               PPE           Procedure          Training            Guards         Rest/ Break
6. List Specific Hazards
7. Chemical List

8. Personal Protective Equipment
Eye
Face
Head
Hand
Foot
Clothing
Respiratory
Other
C Continously (C) 67-100%
F Frequently (F) 34-66%     DO NOT DELETE
O Occasionally (O) 1-33%
N Not Application (N) 0%
  Clear Form
LETE

				
DOCUMENT INFO
Shared By:
Categories:
Tags: JSA_Form
Stats:
views:89
posted:5/12/2010
language:English
pages:3