JSA (Job Safety Analysis)
JSA
Site Safety Co-ordinator - Person Responsible for Site
Date: 
Job No:   
Name:
Client: 
Signature:
Client Contact: 
Phone No:
Phone No: 
Scope and Description of Job
Emergency Planning
Site Location: 
Emergency meeting place identified: 
Trained First Aider:  
Key Contact Name & No: 
First Aid Kit Location:
Behind seat in ute
Emergency Services:
Dial - 111
NRC Environmental Hotline:      
08   
0    
0    
 5    
0    
4    
 63   
9              
National Poisons Centre:           
0    
8  
00 764 766 (POISONS)
Notification of Worksafe or Affected Parties
Does Worksafe Need to Be Notified?
Yes
No
Worksafe Contact 0800 030 040 / online portal
Other Affected Parties/Neighbours etc
Contact Phone / Text
By Who
When
All property owners contacted prior to entry 
Contact office of any near misses
09 439 0050
Near miss/incident, record in register, discuss Monday toolbox 
meetings
5 Step Safety Check
5 Planks of Communication 
1) Step back and look.
1) Ask
2) Think through the job
2) Listen
3) Look for the hazards
3) Think
4) Manage & communicate hazards
4) Evaluate
5) Do the job safely
5) Respond
IF IN DOUBT, STOP/ASK

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JSA (Job Safety Analysis)
Score 
Score After
Enviro Hazards or Sensitive Areas
Before
Control  Procedures (Refer Hazard Rating Matrix) 
Chemical drift
4
Operators only spray in suitable conditions (winds under 
2
15km)
Chemical Spill
10
Spill kits are available on every vehicle. If chemical is 
4
spilled apply bunding and soakage mats around chemical 
to avoid contamination of any waterways. Soak chemical 
and dispose of correctly in approved disposal area. 
Ensure all PPE is used correctly in an incident.
Spray drift inhalation
10
Applicators to wear correct PPE at all times while 
6
spraying is under way. Random checks will be undertaken 
by supervisor.
Chemical Name
PPE Required
Tick
MSDS? Hi-viz Long Sleeved Overalls
Safety Boots
Sun Hat or Hard Hat
Gloves (for handling concentrate)/ safety gloves
Face Shield(for handling concentrate) or Glasses
Respirator
Waterproof clothing for handling chemical
Other?
Score 
Score After
Site Specific Hazards 
Before
Control Procedures (Refer Hazard Rating Matrix)
Residents nearby & other people onsite
10
Signage, identify keep KEEP OUT area, speak to any 
6
personnel who come onsite or coud be affected. 
Induct all persons onto site so they know 
risk/hazards.
OTHER SITE SPECIFIC HAZARDS TO BE ENTERED WHEN IDENTIFIED

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JSA (Job Safety Analysis)
Score 
Score After
Task Specific Hazards 
Before
Control Procedures ( Refer Hazard Rating Matrix)
Accidents on property (vehicle use/operation)
6
Speak to land owner prior, identify any obstuctions 
3
(troughs, holes etc).
Entering and exiting vehicles
6
Always maintain 3 points of contact when entering and 
3
exiting vehicles/machines
Driving on open roads
6
Only licensed driver to drive,  drive to conditons and obey 
4
road rules at all times.
Electric Fences
3
Communicate with land owner which fences are electric 
2
and have them turned off where possible.
Tree Felling
10
Assess the situation, establish safe escape route prior to 
6
felling, fell trees according to ACOP, don’t attempt 
anything your not comfortable with, Identify any hazards 
on a site specific bases- record and discuss safest way to 
carry out the task. if it's too dangerous, dont do it.
Wet slippery terrain
5
If in doubt check the area you need to access. Use 
2
caution at all times to ensure safety in the work place. 
OTHER TASK SPECIFIC HAZARDS TO BE ENTERED WHEN IDENTIFIED
Employee & Visitor Sign-In & Hazard Acknowledgement
Date
Name
Sign
Date
Name
Sign

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JSA (Job Safety Analysis)

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