JSA FORMS JSA Template BASIC FACTS Job Identification Work

							               JSA FORMS




JSA Template
                           BASIC FACTS


Job Identification:




Work Objectives




Work Location(s):




Operator Identification:




Production Standards:




Shift/Shift Length:




Job Rotation (if any)




JSA Date/Time:

JSA Team Members:



JSA Template
               WORK STATION LAYOUT




JSA Template
                 EQUIPMENT AND TOOLS



          Item                         Hazard




JSA Template
                 PARTS HANDLED



          Item                   Hazard




JSA Template
                 PROCESS CHEMICALS



          Item                       Hazard




JSA Template
               MAJOR TASKS AND WORK ELEMENTS
                    (list tasks and elements)




JSA Template
                            ELEMENTAL ANALYSIS
                            (one page per element)



Element Description:




Hazards from "normal" operations:




Hazards from human error:




Hazards from process/hardware failure:




Hazards from nearby operations:




JSA Template
                            ELEMENTAL ANALYSIS
                            (one page per element)



Element Description:




Hazards from "normal" operations:




Hazards from human error:




Hazards from process/hardware failure:




Hazards from nearby operations:




JSA Template
                            ELEMENTAL ANALYSIS
                            (one page per element)



Element Description:




Hazards from "normal" operations:




Hazards from human error:




Hazards from process/hardware failure:




Hazards from nearby operations:




JSA Template
                            ELEMENTAL ANALYSIS
                            (one page per element)



Element Description:




Hazards from "normal" operations:




Hazards from human error:




Hazards from process/hardware failure:




Hazards from nearby operations:




JSA Template
                             HAZARD DESCRIPTION
                              (one page per hazard)


Hazard:




Associated Tasks:




Likely accidents/injuries/disorders:




Probability:




Severity/Seriousness:




JSA Template
                             HAZARD DESCRIPTION
                              (one page per hazard)


Hazard:




Associated Tasks:




Likely accidents/injuries/disorders:




Probability:




Severity/Seriousness:




JSA Template
                             HAZARD DESCRIPTION
                              (one page per hazard)


Hazard:




Associated Tasks:




Likely accidents/injuries/disorders:




Probability:




Severity/Seriousness:




JSA Template
                             HAZARD DESCRIPTION
                              (one page per hazard)


Hazard:




Associated Tasks:




Likely accidents/injuries/disorders:




Probability:




Severity/Seriousness:




JSA Template
               PLAN FOR HAZARD CONTROL




JSA Template