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JSA Form

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2 views

JSA Form

Uploaded by

etfproperti
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Date:

ButterFly Consulting Indonesia Job Safety Analysis


Job Title: Total of person who does the job: Analyzed by:

Work Crew/ Work Crew Leader


Department : Section: Reviewed by: Approved by:

Work Crew Supv/ Delegate. Area Supv/ Delegate. F/S Supv/ Delegate. Work Crew Supt/ Delegate.

Personal protective equipment (PPE) :


 Write down correct specifications of personal protective
Put on PPE required for a safe job. equipment required (Consult HSE Dept) :

1. Safety hat / helmet 6. Face shield 11. SCBA 16. Safety shoes / boots
2. Safety glasses 7. Ear plugs / muffs 12. Gloves – Ordinary 17. Rubber boots
3. Goggles – ordinary 8. Dust mask 13. Gloves - Chemicals 18. Prot. Clothing / Apron
4. Goggles – tinted lenses 9. Air-purifying respirator 14. Gloves – Thermal 19. Body harnesses, L-line
5. Goggles – Chemicals 10. Air-line respirator 15. Rubber gloves 20. Life vest
Sequence of Basic Job Steps Potential Hazards Protective Equipment Safe Procedures

Note : Stop jobs, if found irregularities or changed from the JSA to further discuse with all departments involved.
Catatan : Stop pekerjaan, jika didapati penyimpangan atau perubahan dari JSA ini untuk di diskusikan lebih lanjut dengan semua departemen yang terlibat.

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