Job Safety Analysis Assessment sample. Edit it or build your own.

Job Safety Analysis Assessment Form

A job safety analysis (JSA) assessment form to review the quality and completeness of a specific JSA. Checkout the Forms Library »

Job Safety Analysis Assessment - Printable PDF
Download a printable Job Safety Analysis Assessment (PDF).

What is a JSA Assessment?

A JSA (Job Safety Analysis) Assessment is a risk assessment process use to determine the effectiveness of a specific JSA as undergone by a team. During this review, questions are asked such as:

  • Was the job ready for execution: adequate planning completed with appropriate risk assessment carried out and any associated requirements identified in advance and appropriately addressed?
  • Were appropriate personnel involved in the JSA development?
  • Is the task description full and clear?
  • Was all PPE checked and satisfactory?
  • Was the Person In Charge clearly identified and PIC protocol in effect?
  • Was all appropriate training completed for job task performed?
  • Are appropriate specific written instructions or procedures available?
  • Are the instructions adequate?
  • Were all potential hazards identified?
  • Were all Go-Card questions answered?
  • Have all members of the work team signed the JSA?
  • Are all persons aware of correct actions to be taken in emergency?
  • If any deviation to plan occurred was the job stopped and the JSA appropriately amended for scope change?

This form is a sample report which can be imported into your KPA EHS account. All forms including this one can be easily modified to fit your organization's policies and procedures.

Don't have a KPA EHS account? Download the printable Job Safety Analysis Assessment PDF form so your team can fill out a paper copy.

Check out the forms library.
Check out the forms library.

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