Document Title: Revisi : 00

Fomulir HSE
Document no.: Page:
GMS-HSE-Form-08 1 of ….

DATE: JOB SAFETY JSA TEAM MEMBERS

ANALYSIS
WORK ACTIVITY (JOB):
LOCATION:
SUPERVISOR: Rev.: Date:
PERSONAL PROTECTIVE EQUIPMENT AND SYSTEM REQUIRED TO PERFORM THIS JOB
Hard Hat Leather Gloves Goggles Work Permit Required
Safety Shoes Work Vest Barricade Other …………..
Safety Glasses Safety Harness Fire Extinguisher
Work Gloves Face Shield Lock Out/ Tag Out
Sequence of basic job Potential hazards Recommended to eliminate or Persons In Charge
steps reduce potential hazards (PIC)
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Sequence of basic job Potential hazards Recommended to eliminate or
steps reduce potential hazards

3 of __
Sequence of basic job steps Potential hazards Recommended to eliminate or reduce
potential hazards

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