Blank JSA Form

It is deliberately minimal — the columns are the JSA columns, nothing more — so it prints to one page and the crew can fill it in with a pen. The scoring is optional: where the site uses the 5×5, the score column is there; where it does not, leave it blank and the form still works.

How to use the template

1. Print the form — one page, or two for a long job
2. Fill the header by hand — the job, the location, the date, the preparer
3. Write the steps in the first column, one clear action each
4. For each step, write the hazards, the existing controls, and the new control
5. Score the step where the site uses the 5×5 — or leave it blank
6. Sign the prepared-by and the crew-briefed lines before the work starts

Worked example

A blank form filled in by hand for the relamping of the mezzanine: the steps reach the light, replace the fitting, lower the ladder; the hazards the fall, the live fitting, the dropped fitting; the controls the insulated tool, the LOTO, the ladder secured; the scores where the site uses them. One page, a pen, and the job is covered.

Standard & legal context

The blank form is the JSA in its paper form, the document the OSHA 1910.120(h) and 1910.119 hazard assessment expects and the UK task-level risk assessment under the MHSWR 1999. The columns follow the standard JSA layout, and the 5×5 score column is the ACoP L80 convention where the site uses it. The form is the medium; the method is the five steps applied to the task.

Common mistakes

1. Filling the form after the job — the JSA is before the work, and the form in the hand at the job is the point
2. Skipping the sign-off lines — the prepared-by and the crew-briefed are the accountability, and the unsigned form is the one the investigation questions
3. Over-filling — the blank form is minimal on purpose; the long version is the full JSA template
4. No score and no control on the high steps — where the step is high, the control is the line, even without the number