Job Safety Analysis Form
Job:	Effective Date __________________ # of Pages ____ of ____ 
Department ____________________________ 	
Prepared By: 
Date: 	Reviewed By: 
Date: 	Approved By: 
Date: 	
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. Personal Protective Equipment	
Eye	Face	Head	
Clothing	Hand	Other	
Foot_Respiratory	Other			
9. Procedure - step by step