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Injury and Illness <br /> Prevention Program 2.22 <br /> Appendix B - Example Job Safety Analysis Form <br /> ❑ NEW <br /> JOB SAFETY ANALYSIS Ctrl. No. DATE: ® REVISED PAGE i of 2 <br /> JSA TYPE CATEGORY WORK TYPE WORK ACTIVITY(Description) <br /> DEVELOPMENT TEAM POSITION/TITLE REVIEWED BY: POSITION/TITLE <br /> REQUIRED AND/OR RECOMMENDED PERSONAL PROTECTIVE EQUIPMENT <br /> ❑ LIFE VEST ❑ GOGGLES ❑ AIR PURIFYING ❑ GLOVES: <br /> ❑ HARD HAT ❑ FACE SHIELD RESPIRATOR ❑ OTHER <br /> ❑ LIFELINE/BODY HARNESS ❑ HEARING PROTECTION ❑ SUPPLIED RESPIRATOR <br /> ❑ SAFETY GLASSES ❑ SAFETY SHOES: ❑ PPE CLOTHING: <br /> REQUIRED AND/OR RECOMMENDED EQUIPMENT <br /> Required Equipment: <br /> COMMITMENT TO SAFETY-All personnel onsite will actively participate in hazard recognition and mitigation throughout the day by verbalizing SPSAs. <br /> Analyze <br /> ZPOTENTIAL HAZARDS <br /> Each Job or Operation A hazard is a potential danger. Using the first two columns as a guide, decide what <br /> consists of a set of tasks/ actions or procedures are necessary to eliminate or <br /> steps. Be sure to list all the Break hazards into six types: minimize the risk. List the recommended safe operating <br /> steps needed to perform 1. Contact-victim is struck by or procedures. Say exactly what needs to be done-such <br /> job. strikes an object; as "use two persons to lift." Avoid general statements <br /> 2. Caught-victim is caught on, such as, "be careful." <br /> caught in or caught between <br /> objects; <br /> 3. Fall-victim falls to ground or <br /> lower level(includes slips and <br /> trips); <br /> 4. Exertion-excessive strain or <br /> stress/ergonomics/lifting <br /> techniques; <br /> 5. Exposure-inhalation/skin <br /> hazards; <br /> 6. Energy Source—electricity, <br /> pressure, compression/tension. <br /> 1/2019 Corporate Health and Safety Management Program ROUX <br />