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Job Safety Analysis
Task steps, hazards and controls for a pre-job safety briefing, with crew sign-on.
MILLWRIGHT QC
Precision Maintenance QC
millwrightqc.com
Project
Job No.
Client
Sheet ____ of ____
JSA No.
Date
Time
Contractor / Crew
Location / Work Area
Prepared By
Task / Scope of Work
Permits Required
None
Lockout / Tagout
Line Break
Hot Work
Confined Space
Excavation
Elevated Work
Critical Lift
PPE Required
Hard Hat
Safety Glasses
Face Shield
Hearing
Cut-Resistant Gloves
Chemical Gloves
Steel Toe Boots
Metatarsal Guards
Fall Protection
Gas Monitor
Energy Isolation Point(s)
Stored Energy — springs, load, pressure, rotation
Lift Plan Required / Ref
#
Job Step
Potential Hazard
Controls / Safe Work Practice
1
2
3
4
5
6
7
8
Muster Point
Nearest Hospital
Emergency Contact / Phone
First Aid / AED Location
#
Crew Name (print)
Company
Signature
1
2
3
4
5
6
7
8
Prepared by / Date
Supervisor / Competent Person / Date
Safety Representative / Date
MW-JSA-01 | Rev 0
Free blank form from
MILLWRIGHT QC
— millwrightqc.com