JSA Form

Date : JSA No. : Name Sign

Job Title : Person In charge :

Location. : 1.
2.
Standard Requirement : Originator Team : 3.
Standard PPE: Safety Helmet Safety shoes Special PPE : 4.
Safety glasses Ear protection
Special attention : Reviewed by :
 JSA Form

Date : JSA No. : Name Sign

Job Title : Person In charge :

Location. : 1.
Originator Team : 2.
Standard Requirement : 3.
Approved by :
Jika kondisi / cuaca buruk STOP semua kegiatan dan Evaluasi ( if the condition or weather getting worst, please stop all activity and conduct evaluation)
 JSA Form

Date : JSA No. : Name Sign

Job Title : Person In charge :

Location. : 1.
Standard Requirement : 2.
Originator Team : 3.
No Work Steps Hazards Identified Hazards Effect Risk Factor * 4.Safety
Measures & Residual Risk
. Prevention Factor *)
 JSA Form

Date : JSA No. : Name Sign

Job Title : Person In charge :

Location. : 1.
Originator Team : 2.
Standard Requirement : 3.
Type dari cedera atau kerugian Tindakan untuk mencegah
Langkah kerja secara Bagaimana bisa terjadi mencedrai
berurutan orang atau kerugian L C RF agar tidak terjadi cedera atau L C RF
kerugian
 JSA Form

Date : JSA No. : Name Sign

Job Title : Person In charge :

Location. :
Standard Requirement :

1.
2.
Originator Team : 3.
 JSA Form

Date : JSA No. : Name Sign

Job Title : Person In charge :

Location. : 1.
Standard Requirement : 2.
Originator Team : 3.
No Work Steps Hazards Identified Hazards Effect Risk Factor * 4.Safety
Measures & Residual Risk
. Prevention Factor *)
 JSA Form

Date : JSA No. : Name Sign

Job Title : Person In charge :

Location. : 1.
Originator Team : 2.
Standard Requirement : 3.

Tindakan untuk mencegah

Langkah kerja secara Bagaimana bisa terjadi mencedrai
berurutan orang atau kerugian
Type dari cedera atau kerugian L C RF agar tidak terjadi cedera atau L C RF
kerugian
 JSA Form

Date : JSA No. : Name Sign

Job Title : Person In charge :

Location. :
Standard Requirement :

1.
2.
Originator Team : 3.
 JSA Form

Note : * : Without Control *): With Control

L = likelihood C = Consequences RF = Risk Factor
Risk Factor (RF) Determined Control
Likeliho Severity / consequence Tingkat Risiko Penetapan Pengendalian
X =
od (L) Keparahan (C
Score Level Tingkat pengendalian Hierarchy of Control
Frequent =5 Catastrophic = 5 14-25 High (H) E= 1+2+3+4+5 1= Eleminasi
Probable = 4 Major = 4 11-13 Medium (Med) H= 3+4+5 2= Substitusi
Occasional = 3 Moderate/serious =3 7-10 Moderate (Mod) M= 4+5 3= Engineering technik
Unlikely = 2 Minor = 2 4= Administrasi
1-6 Low (L) L=5
Improbable = 1 Negligible = 1 5= APD
JSA Form