Job Safety Analysis Template - Free Download
4.6,
3983
votes
Please vote for this template if it helps you.
Job/Task: ___________________________________________________ Date: ___________
Work Location: _____________________________________
Employee(s): _________________________________________________________________
• What is the most hazardous part of this job and what are you going to do to control the hazard_____________________________________
New
Revised
In case of an incident, the following people
will be contacted:
Supervisor:________________________
Safety:___________________________
Other:_____________________________
• Are you properly trained to complete these tasks _____________________________ SSE___________________ Mentor __________________
• What do you need to ensure this job is completed incident and injury free _____________________________________________________
• What conditions, job changes or distractions could call for the need to use Stop Work Authority_____________________________________
Sequence of Job Steps Potential Hazard(s)
Recommended Action/Procedure
Additional Personal
Protective Equipment Req’d
face shield chemical goggles chemical protective clothing rubber boots chemical resistant gloves
leather gloves cut resistant gloves respiratory protection ______________________ arm protection
hearing protection fall protection Other ____________________________________________________
Required Permits/Safe Work
Plans
General SWP Hot Work Permit Confined Space Entry Excavation and Trenching Lift Plan/Crane Ops
Work in proximity to Overhead Conductors Simultaneous Operations
Gas Detection
Equipment Needed
H
2
S monitor LEL, O
2
, H
2
S, CO Monitor Other _______________________________________________
List hazardous substances
MSDS reviewed
yes n/a
Site Control
barricades post signs caution tape designated area for vehicles heavy equipment spotter
establish meet and greet process Other_________________________ Other _______________________
Environmental Conditions
Weather: Terrain: Wildlife:
Hazardous Energy Control
LO/TO checklist complete LO/TO devices in place energy isolation verified Stored Energy _______
electrical hydraulic pneumatic mechanical thermal chemical
Line Of Fire _________
Tools and Equipment
pre-use inspection complete trained in use of tool/equipment
List tools/equipment being used:____________________________________________________
Examine each step
carefully to find and
identify hazards or
potential dangers that
could lead to injury,
illness or damage.
Consider the following:
Chemical Hazard:
_Inhalation _Skin Contact
_Absorption _Injection
_Ingestion
Biological Hazards:
_Bloodborne Pathogens
_Mold _Valley Fever
_Plant/Insect/Animal
Physical Hazards:
_Electrical
_Fire/Explosion
_Noise _Radiation
_Thermal Stress
_Pinch Point/Line of Fire
_Slips/Falls
_Strike against/Struck by
Ergonomic Hazards:
_Repetition
_Forceful exertion
_Awkward Posture
_Contact Stress
_Vibration
_Work Area Design
Copyright © 2008 Chevron Corporation All rights reserved.
