Job Safety Analysis

CCR, Title 8, Subchapter 4, Article 3, Section 1511 (b)

(b) “Prior to the presence of its employees, the employer shall make a thorough survey of the
conditions of the site to determine, so far as practicable, the predictable hazards to employees and
the kind and extent of safeguards necessary to prosecute the work in a safe manner.”

Date: _________________________

Project: _______________________________________________________________________

Conducted by: _____________________________________________________________________

Job Safety Analysis (Place a Check Mark Next to Each Item)

 Site Specific Job Hazards:

__ Work on elevated structures

__ Work from Ladders/Scaffolds/Scissors Lift/Man Lifts
__ Use of Hand and Power Tools
__ Exposure to Harmful Vapors/Substances
__ Heavy Equipment Vehicles and Traffic at Job Site
__ Housekeeping (Stacks of Materials/Equipment/Storage Containers/Trailers)
__ Electrical (Location of electrical panels/vaults/wires/etc.)
List:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

1
 Job Safety Analysis Checklist

Task Unsafe Condition, Action, Preventative or Corrective Action

or Other Hazard

2
Job Safety Analysis:

 Required Personal Protective Equipment:

__ Hard Hats
__ Hearing Protection
__ Safety Glasses
__ Fall Protection
__ Chemical Resistant Gloves
__ Appropriate Footwear
__ Protective Clothing (Tyvek)
__ Respirators (air-purifying/dust masks)

__ Other: _________________________________________________

 Work Access: __ Step Ladders

__ Extension Ladders
__ Scissors Lift
__ Man Lift
__ Scaffold
__ Rolling Scaffold
__ Other
______________________
______________________

 Work Site:
__ Exterior Overhead Obstructions (power lines/etc.)
Identity and Location:
___________________________________________
___________________________________________

__ Interior Overhead Obstructions (sprinklers/power lines/building

structure)
Identity and Location:
___________________________________________
___________________________________________

Emergency Evacuation Procedures: (Chemical Spill/Fire/Earthquake)

___________________________________________________________________________________
___________________________________________________________________________________

3
Job Safety Analysis – Verification

Note: The foreman and employees must review the Job Safety Analysis. After review, a copy of this
must be maintained at the job site.

Site: ______________________________________________________________________

Foreman: ______________________________________________________________________

Date: ________________________________________________

Employees:

By signing below, I agree that I have been briefed and understand the contents of the Job Safety
Analysis for this project.

Print Name Signature Date

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________