Sample FORM JOB SAFETY ANALYSIS by TPenney

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									     Sample FORM                                      JOB SAFETY ANALYSIS

PRINCIPAL CONTRACTOR/RELEVANT PERSON                      CONTRACT                                                                    SITE ADDRESS
Insert name here                                          Insert contract here e.g. Subdivision Ormeau                                Insert site address here

WORK AREA                                                 ACTIVITY                                                                    DATE
Insert work area e.g. Division 1                          Insert name of activity here e.g. Replace drivers seat excavator            Insert date assessment completed here



  STEPS IN ACTIVITY                POTENTIAL             EXISTING                  RISK               RISK CONTROL           RESIDUAL RISK           RESPONSIBLE                 DATE
                                    HAZARDS             CONTROL                   SCORE                 MEASURES                SCORE                 PERSON
                                                        MEASURES                   1- 25                                          1- 25
      Insert steps in activity   Insert all           If reviewing an       Using Risk Matrix      Check legislation and     Using Risk Matrix      Insert title or name   Insert date control
      in this column in the      foreseeable          activity insert       assess the risks of    insert new control        insert new risk        of persons             measures must be
      sequence the activity      hazards associated   existing control      existing/control       measures in this          score here             responsible for        met in this column
      is to be carried out,      with each step in    measures in this      measures and insert    column. If no control     Risk Matrix - Form C   following,
      step by step               this column          column                risk score here.       measures written in                              implementing, or
1                                                                           Risk Matrix - Form C
                                                                                                   legislation use
                                                                                                   hierarchy of controls
                                                                                                                                                    maintaining control
                                                                                                                                                    measures in this
                                                                                                   and consult with                                 column
                                                                                                   workers and
                                                                                                   professionals


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THE FOLLOWING PERSONS HAVE RECEIVED TRAINING ON THIS JSA



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Name and sign

								
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