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Project Information
Additional Safety Measures Concerning Critical Tasks
If any of the above CRITICAL TASKS apply, details of work steps and safety controls MUST be listed in the JSA below
Anticipated Hazards
Check applicable anticipated or potential hazards
Ensure that all hazards identified are addressed in JSA below | Risk Levels: A = High B = Medium C = Low
Job Steps Sequence
No job steps added yet. Select a template or add a custom step.
Tools & Equipment
Auto-consolidated from job steps
Add job steps to see required tools
Required PPE
Auto-consolidated from job steps
Hard hat
High-visibility vest
Safety glasses
Steel-toed boots
Crew Members
No crew members added yet
Signature line (will show on print)
JOB SAFETY ANALYSIS (JSA) FORM
[Company Name]
Project Information
Company: _________________
Date: 2026-06-18
Site/Project Address: _________________
Project Name: _________________
Work Area: _________________
Weather: Clear
Temperature: 20°C
Supervisor: _________________
Safety Rep: _________________
Critical Tasks
Work At Heights
Deep Excavations (More than 8 feet)
Confined Space
If any of the above CRITICAL TASKS apply, details of work steps and safety controls MUST be listed in the JSA below
Anticipated Hazards
CRANE HOISTING OPERATIONS
Use of Saws, Grinders, other Cutting Equipment/Tools
CONCRETE POURING OPERATIONS
Slip, Trip, Fall Hazards or Pinch Points, Awkward Body Position
MOVEMENT OF HEAVY EQUIPMENT/MOBILE EQUIPMENT
Erection of Scaffolding or Shoring Systems
TRAFFIC, OTHER TRADES
Forming Operations; Build, flying forms
HOUSEKEEPING & LIGHTING CONDITIONS
Stripping/Removing Form Work/Shoring/Scaffolding
Work Environment: Dust, Chemicals, Silica, other
Other: _________________
Risk Levels: A = High | B = Medium | C = Low
Job Safety Analysis
| # | Sequence of Basic Job Steps | Potential Hazards | Risk | Safety Controls |
|---|---|---|---|---|
| No job steps defined | ||||
Tools & Equipment
No tools specified
Required PPE
Hard hat, High-visibility vest, Safety glasses, Steel-toed boots
Crew Acknowledgment & Signatures
No crew members listed
Supervisor Approval
APPROVED BY: _________________
SIGNATURE:
DATE: