"Job Safety Analysis Form"

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Job Safety Analysis Form
Event: ________________________
Effective Date: ____/____/_______ Number 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 = 100% - 67%; Frequently = 66% - 34%; Occasionally = 33% - 1% Not Applicable = 0%)
___ Standing
___ Pulling
___ Kneeling
___ Walking
___ Climbing
___ Reaching
___ Sitting
___ Stooping
___Carrying (___ lbs. ___ distance)
___ Pushing
___ Bending
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Job Safety Analysis Form
Event: ________________________
Effective Date: ____/____/_______ Number 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 = 100% - 67%; Frequently = 66% - 34%; Occasionally = 33% - 1% Not Applicable = 0%)
___ Standing
___ Pulling
___ Kneeling
___ Walking
___ Climbing
___ Reaching
___ Sitting
___ Stooping
___Carrying (___ lbs. ___ distance)
___ Pushing
___ Bending
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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. List of Chemicals:____________________________________________________________
8. PPE:
Eye
_______________
Face
_______________
Head _______________
Clothing ______________
Hand _______________
Other_______________
Foot
_______________
Respiratory ___________
Other_______________
9. Procedure Details:
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