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Job Safety Analysis Worksheet/Safe Work Procedure
Part 1: Job Safety Analysis Document Control Record
Job/Task: MANAGER / CSM SITE VISIT
Site:
This JSA covers:
JSA / SWM No:
Rev #:1
Hymix Australia Pty Ltd
PPE REQUIREMENTS
ADDITIONAL PPE REQUIREMENTS
ACN 35000582221
Minimum requirement of uniform confirmed as:

Level 5, 75 George Street
Parramatta NSW 2150
Po Box 610
Parramatta NSW 2124

Hi visibility shirts (As per current Hymix issue).

Standard Company safety boots
Safety vest must:
Telephone (02) 9407 7400

Have reflective tape
Operations Fax (02) 9407 7499

Be worn for all work between dusk & dawn work
JSA Initiated by:
OHS Review:
Rev. Date:
Management Review:
Date
Date:
Approved by
Date:
Signature:
Part 2: Hazard Analysis and Control Worksheet
Risk Rating: See table below
Step
No
1
Process Steps
Potential Hazard/s
List the steps needed to do the job
Against each step list potential hazards that
in the sequence needed to be done.
could cause injury when the job’s done.
Assess to site and enter
1. Vehicle Damage
2. Hit by moving equipment.
Tripping, slipping or falling
2
Walking around site
3. Hit by moving equipment.
Tripping, slipping or falling
3
At all times while on
site
4. Personal injury
JSA / SWM No:
Rev #:4
Hazard Control Measures
Initial Risk
Score
For each hazard identify control measures to
eliminate or minimise the risk of injury.
1. Park off site if possible or in dedicated car parking if
provided
2. Look for moving plant and equipment before entering
site. Assess site for tripping or slipping hazards.
Report directly to site office without making any
unnecessary detours. Wear all appropriate PPE.
3. Look for moving plant and equipment while on site.
Assess site for tripping or slipping hazards. Be
escorted through the site by a site supervisor. If
stopping stand in an appropriate position which will
not interfere with work. Wear all appropriate PPE.
4. Obey site safety signs and instructions by authorised
site personnel
Rev. Date:
New Risk
Score
Action required by
(Print name of person)
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Job Safety Analysis Worksheet/Safe Work Procedure
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5
6
7
8
9
10
JSA / SWM No:
Rev #:4
Rev. Date:
Pg 3 of 4
Job Safety Analysis Worksheet/Safe Work Procedure
Part 3: Job Safety Analysis Plan
Brief description of work to be undertaken:
.
Key safety issues to be managed and key safety controls to be implemented (e.g. exposure to road traffic, hazardous substances, manual handling, falls):
Reference / detail applicable section/s of:
Legislation
Detail qualifications and experience of key personnel:
Codes of Practice
Project OHS&R Management Plan
Site OHS&R Management Plan
Detail key individual duties and responsibilities for safety:
Manufacturer / Supplier recommendations/specifications
Detail all training required to do the work:
List Engineering details, WorkCover or internal approvals required to do work:
List certificates of Competency, Licenses required to operate plant perform tasks:


PCM induction


List plant and equipment to be used for task:
Comment on safety inspections performed on plant, equipment and work areas







Phone contacts
of key personnel
JSA / SWM No:
Name:
Name:
Name:
Name:
Number :
Number:
Number:
Number:
Rev #:4
Rev. Date:
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Job Safety Analysis Worksheet/Safe Work Procedure
Risk Assessment Matrix
Likelihood 
Practically
impossible
Very
Remote
Infrequent
Frequent
Constant
Risk Score
Insignificant –
1
1
1
2
3
1
Low Risk
No action/controls required,)
Minor -
1
1
2
3
3
2
Moderate Risk
Action required - time frame variable/controls required - may
be low level,
Moderate -
2
2
3
3
4
3
High Risk
Action required – time frame variable/controls required – will
be high level,
Serious -
3
3
4
4
4
4
Extreme Risk
Immediate action required/specific controls must be
implemented.
Major -
3
4
4
4
4
Consequences

Part 4: Worker Induction Record
Sign off and acceptance of proposed work method and associated responsibilities
No
Surname
First Name
ID No
Classification
Employed by
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
JSA / SWM No:
Rev #:4
Rev. Date:
Signature
Date