AMC RISK MANAGEMENT/OHS&E

Job Safety Analysis Worksheet

This form applies for tasks / jobs which have no existing SOP and must be completed before the
task / job commences. Tick only the boxes as marked where hazards may apply.
Task/ Job: ____________________________ Location: _____________________________
Persons undertaking assessment: _____________________ Date of assessment: ________
Hierarchy of Controls: 1) Elimination 2) Substitution 3) Engineering 4) Administration 5) PPE
Permits Required: (Tick appropriate box if required)
Hot Work
Excavation Work

Confined Space
Maintenance
Inspection/Testing

Working at Heights
Bunkering/Refueling

High Voltage

Other: (List)_________________________________________________________________________
Licences/Accreditation Required: (Tick appropriate box if required)
Fork Lift Licence
Elevated Work Platform
Working at Heights
Confined Space
Car, MR/HR Truck

Crane/Derrick
Dogging/ Rigger
Scaffolding
Plumbing/Gas works (LPG)
Bus/Public Vehicle

First Aid
Boat Licence
Coxwains Cert. or higher
Fast Rescue Vessel

Other: (List)________________________________________________________________________
PPE Required: (Tick appropriate box if required)
Safety Glasses/Face Shield
Gloves
Fall arrest harness
Sun Protection/Sunscreen

Overalls/Protective Clothing
Hard Hats
Safety Footwear
Laboratory Coat

Hearing Protection
Respiratory Equipment
Personal Floatation Device

Other: (List) ______________________________________________________________________

Hazards: (Tick appropriate box if identified / required)
Working at Heights
Stored Energy
Mobile Plant
Pinch Points
Falls/overhead work
High Voltage
Fire protection/prevention
Fuels i.e. Diesel/Petrol
Gases i.e. acetylene/oxygen
Hypo/Hyperthermia
Issue date: 28/01/10
Issued by: D. Waldron

Issue No: Five

Page 1 of 5
Review: 01/11

Confined Space
Sharp Cutting Edges
Slippery Surfaces
Isolation
Lighting
High Speed
Tripping Hazard
Concealed servicesair/water/oil/electrical wiring
Bites & Stings
Laser Equipment
IF PRINTED THIS
DOCUMENT BECOMES
UNCONTROLLED

Fumes
Noise
Hazardous substances
Manual handling
Non skilled/trained personnel
Communication equipment
Repetitive actions required
High pressureoil/steam/water/air
Person overboard

Other: (List) ________________________________________________________________________

Flammable or combustible substances present (List) ____________________________________

Issue date: 28/01/10

Issued by: D. Waldron

Issue No: Five

Page 2 of 5
Review: 01/11

IF PRINTED THIS
DOCUMENT BECOMES
UNCONTROLLED

Job Safety Analysis Worksheet

Persons who identify hazards must ensure that all personnel undertaking tasks are advised of the hazards prior to work
commencing. This form MUST be completed before any work commence and is to be retained in the relevant work area with
copies available for use, inspection or audit at any time.
Job / task steps

Hazard Identified

Hazard control required

Resp
Per

Est
Comp
Date

Act
Com
Date

Persons undertaking the job / task must read & sign this form to ensure they understand the identified hazards.
Personnel signatures:
(Name) _____________________________ Date: ______________ (Name) ___________________________ Date: ________________
(Name) _____________________________ Date: ______________ (Name) ___________________________ Date: ________________
(Name) _____________________________ Date: ______________ (Name) ___________________________ Date: ________________
Issue date: 28/01/10
Issued by: D. Waldron

Issue No: Five

Page 3 of 5
Review: 01/11

IF PRINTED THIS
DOCUMENT BECOMES
UNCONTROLLED

Job / task steps

Issue date: 28/01/10

Issued by: D. Waldron

Hazard Identified

Issue No: Five

Page 4 of 5
Review: 01/11

IF PRINTED THIS
DOCUMENT BECOMES
UNCONTROLLED

Hazard control required

Resp
Per

Est
Comp
Date

Act
Com
Date

Issue date: 28/01/10

Issued by: D. Waldron

Issue No: Five

Page 5 of 5
Review: 01/11

IF PRINTED THIS
DOCUMENT BECOMES
UNCONTROLLED