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Job Safety Analysis Form

Task  ________________________
Effective Date  _______ # of Pages ____ of ____
Department  ____________________________
Prepared By:
Reviewed By:
Approved By:
1.  Equipment Operated
2.  Environmental Conditions
Inside      Outside       Cold      Heat      Wet      Dust      Vapors/Mist            
Noise      Vibration      Other   ___________________
3.  Primary Job Functions & Position
Lifting       Grasping        Pushing       Sitting       Reaching      Bending
Kneeling   Standing        Pulling         Squatting   Other ____________
4.  Physical Demands
Continuously (C) 67-100%                 Occasionally (O) 1-33%
Frequently (F) 34-66%                      Not Applicable (N) 0%

Standing   ____     Walking     ____    Sitting       ____     Pushing   ____

Pulling      ____     Climbing   ____    Stooping   ____     Bending   ____

Kneeling  ____     Reaching    ____    Carrying   (______ lbs. _____ distance)

5.  Potential Hazards

Controlled By

Impact PPE         Procedure         Training            Guards
Chemical Contact PPE         Procedure         Training            Guards
Caught on or between PPE         Procedure         Training            Guards
Fall or Slip PPE         Procedure         Training            Guards
Over Exertion PPE         Procedure         Training            Guards
Cumulative Trauma PPE         Procedure         Training            Guards
Other PPE         Procedure         Training            Guards
6.   List of Specific Hazards


7. Chemical List    
8. PPE Eye Face
Eye Face Head
Clothing Hand Other
Foot Respiratory Other
9. Procedure - step by step







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