Free HSE template · JSA / JHA Forms
JSA Example (Filled-In)
The JSA example is a finished JSA, filled in for a work-at-height job — the roofline re-sheeting — so a new user can see the document before writing the first one of their own. Every column is worked: the steps, the hazards, the existing controls, the new controls, the scores, and the sign-off.
JSA Example — the roofline re-sheeting, worked through
Every column filled in for a work-at-height job, so you can see the finished JSA before you write your own. Print it as the site-office reference.
| # | Step | Hazard(s) | Existing controls | Pre | Control to add | Post |
|---|---|---|---|---|---|---|
| 1 | Access by MEWP | Fall | MEWP certified, pre-use done | 15 | Certified MEWP, route marked | 8 |
| 2 | Set the sheet at the edge | Fall | None at the edge | 15 | Harness + anchor at the MEWP point | 8 |
| 3 | Fix the sheet | Dropped sheet | Face protection | 6 | Tie-down for the sheet | 3 |
| 4 | Descend | Fall on the way down | MEWP | 8 | Descent in the MEWP, no descent on the sheet | 4 |
Use it as the reference: read it top to bottom, note how each step is one clear action, how the hazard is the hazard of that step, and how the control closes the gap. Then take the structure and apply it to the job you have in front of you. The example is the template with the answers in.
How to use the template
- Read the header — the job, the location, the date, the classification, the permit
- Read the steps — each one is a clear action, and the order is the order of the job
- Read the hazards per step — the hazard is what can go wrong at that moment
- Read the controls — the existing, then the new, in hierarchy order
- Read the scores — the pre- and post-control, and how the control moved the number
- Take the structure to your job — the same columns, your steps, your hazards, your controls
Worked example
The example is the roofline re-sheeting at 9 m: step 1 access by the MEWP (the fall, 3×5=15, the certified MEWP and the pre-use, residual 2×4=8), step 2 set the sheet at the edge (the fall, 3×5=15, the harness and the anchor, residual 2×4=8), step 3 fix the sheet (the dropped sheet, 2×3=6, the tie-down, residual 1×3=3), step 4 descend (the fall on the way down, 2×4=8, the MEWP, residual 1×4=4). Four steps, the scores moved by the controls, the sign-off complete.
Standard & legal context
The example is the JSA method worked through, the format OSHA 1910.120(h) and 1910.119 expect and the UK task-level risk assessment under the MHSWR 1999. The work-at-height context carries the Work at Height Regulations 2005 duties — the planning, the equipment, the rescue — into the steps. The 5×5 scoring per step is the ACoP L80 convention, and the example shows how the control moves the residual.
Common mistakes
- Reading the example and not taking the structure — the example is the template with the answers, and the point is the structure
- Copying the examples controls onto a different job — the controls are for this job, and the new job gets its own
- Skipping the residual score — the example shows the control moving the number, and the residual is the position the crew works at
- Treating the example as the answer for the permit — the permit-required job carries the JSA and the permit, not the example
Need the sign-off, not just the template?
The template is the preparation; the sign-off is the professional. For the statutory assessments, the audits, the ISO 45001 implementation and the training that comes with them, ask Muhammad Umer — 8+ years across Iraq, KSA and Pakistan, and the programme runs through umer-hse.pro. One message gets the written scope.
Common questions
JSA Example (Filled-In) — answered
What is a JSA example?
A finished JSA, filled in for a specific job, so a new user can see the document before writing their own. This one is a work-at-height job — the roofline re-sheeting — with every column worked.
Why is the example a work-at-height job?
Because the fall is the high-consequence hazard and the work-at-height job shows the JSA at its most important: the scores are high pre-control, the controls are the harness and the anchor, and the residual is the position the crew works at. It is the JSA earning its keep.
Can I use the example for my own job?
Use it as the reference, not the answer. Read the structure, take the columns, and apply them to your job with your steps, your hazards and your controls. The controls in the example are for that job.
How is the example different from the JSA template?
The template is the blank interactive version with the worked example at the bottom; the example is the full worked JSA on its own, for reading. The template is for filling in, the example is for learning.
Does the example show the scoring?
Yes — every step has the pre-control score, the control, and the post-control residual, so you can see how the control moves the number and what the crew works at.
Can I print the example?
Yes — print it as the reference for the site office, or keep it on the screen while you write your own. It is the finished document the crew can see before the first one is written.
Keep building
Related templates
JSA / JHA Template
Free JSA template (job safety analysis / job hazard analysis): the steps, the hazards, the existing controls,
JSA / JHA FormsBlank JSA Form
A blank JSA form you can print and fill in by hand: the job header, the step table, the sign-off lines
Toolkit toolWork At Height Survey
Working HSE tool from the toolkit
THE HEALTH AND SAFETY is an education and knowledge network. The templates are free and open; the professional assessments and audits run through umer-hse.pro.
Safety disclaimer
These templates are practical documents, built to the UK baseline with the US equivalents named on each page. They do not replace a competent person assessment for high-risk work, a statutory assessment, or the advice of your insurer. Where a document has legal force — the fire risk assessment, the COSHH register, the permit to work — the responsible person owns it. Use the template as the preparation, and the competent person as the sign-off.