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Safety Analysis Sheet

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Worksheet to use with Job Safety Analysis

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SAFETY ANALYSIS SHEET JOB_______________________________________________ DATE_____________________ OPERATION_______________________________________ DEPT______________________ OCCUPATION_________________________________________________________________ INJURIOUS CONTACTS POSSIBILITIES WHAT PART OF OPERATION HOW TO ELIMINATE CAUGHT BETWEEN: __________________________________ ________________________ ____________________ __________________________________ ________________________ ____________________ __________________________________ ________________________ ____________________ __________________________________ ________________________ STRIKE AGAINST: __________________________________ ________________________ ____________________ __________________________________ ________________________ ____________________ __________________________________ _______________________ ____________________ __________________________________ _______________________ STRUCK BY: __________________________________ ________________________ ____________________ ___________________________________ ________________________ ____________________ __________________________________ _________________________ ____________________ ___________________________________ _________________________ RECOMMENDED PROCEDURE FOR THIS OPERATION: _______________________________ SIGNATURE

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  • 1. SAFETY ANALYSIS SHEET JOB_______________________________________________ DATE_____________________ OPERATION_______________________________________ DEPT______________________ OCCUPATION_________________________________________________________________ INJURIOUS CONTACTS POSSIBILITIES WHAT PART OF OPERATION HOW TO ELIMINATE CAUGHT BETWEEN: __________________________________ ________________________ ____________________ __________________________________ ________________________ ____________________ __________________________________ ________________________ ____________________ __________________________________ ________________________ STRIKE AGAINST: __________________________________ ________________________ ____________________ __________________________________ ________________________ ____________________ __________________________________ _______________________ ____________________ __________________________________ _______________________ STRUCK BY: __________________________________ ________________________ ____________________ ___________________________________ ________________________ ____________________ __________________________________ _________________________ ____________________ ___________________________________ _________________________ RECOMMENDED PROCEDURE FOR THIS OPERATION: _______________________________ SIGNATURE