Job Safety Analysis Form

PTW Number (If Applicable): New Revised Page 01 to 02

Job being analyzed:

Function/Department doing JSA: Job performers:

Job Area/Location: Tools & Equipment Used:
General Job Requirements/ Common JSA Team Leader: Job had been analysed for potential hazards, appropriate guidance had been obtained in identifying the
- Comply with 12 Orpic Safety Rules hazards and the required controls were discussed and agreed in the JSA Team Meeting.
- PTW must be used for every job
- Coveralls (Flame Redundant /100% Cotton). Name: _____________, Signature: ______________, Date: _______
- Safety Helmet (No older than 3 years from date
of issue). JSA Team Members Names Staff No Signature Company Date
- Safety Shoes (Sole must not be smooth). 1.
- Safety Glasses (Clear), Hearing Protection, 2.
Safety Gloves. 3.
- 1 H2S Gas Alert Clip per group of 5 people is a
minimum requirement in H2S classified areas.
- Adequate levels of Supervision to be maintained
throughout work scope tasks as listed below

TICK THE RELEVANT BOX

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PROCESS SAFETY RULES

12 ORPIC SAFETY RULES

Job Safety Analysis Form

Title of Job: Page # ……..of……..
Sequence of basic Job Steps Potential Hazards Identified Hazard Controls Action By
(Use Hazard Checklist as a guide)

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F01-HSE-OHS-W06