Example Job Safety Analysis (JSA) Worksheet

Industry: construction Operation: Road repair Job: Pavement repair

Task	Who does it	Hazards	How to prevent injury/accident
Operating jack-hammer	Joe Doe	- noise - vibration	- ear protectors - vibration absorbing gloves

Applicable Legislation: OH&S Act and Regulations___________(refer to the act and regulations in your jurisdiction)
Date:__________________________ Developed by: _________________________________