Job Safety Analysis Submission Form

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A Job Safety Analysis (JSA) breaks down the hazards and controls of a specific process. All new processes in the wet lab require a JSA, and any process that requires Personal Protective Equipment (PPE) should have an accompanying JSA.

Please keep in mind that review and evaluation of your submission will take time. You can expect to hear back from us in about a week with some follow-up questions and possible next steps.
Submission Basics



JSA Overvew


Please provide a brief (1-3 sentence) narrative on your process including the purpose/explanation of what you're trying to accomplish.







Hazard & Control Identification

e.g., 2L, 480V, 45kg, 250lbs

Risk Assessment Matrix








catastrophic health or work impact, full evacuation or building damage e.g. uncontrolled spill, major fire, toxic gas. Major - partial or brief evacuation, closure, or work stoppage e.g. safety shower use, isolated fire. Moderate - localized space closure or work stoppage e.g. power outage, leak. Minor - localized impact on space access or comfort e.g. increased foot traffic, clean up efforts, noise. Minimal - not detectable by others in the space e.g. controlled spill, minor first aid injury.
Expected Shared Space Impact

Expected Impact Matrix
Examples: smell, noise, loading dock use/blockage, safety lane blockage, changes to lighting, vibration, electromagnetic radiation, temperature, airflow
Wastes Generated


Give this waste a name

e.g., 3% nitric acid, deionized water




New Chemicals

Additional Comments

Chemical Request Form
You can complete these sections in place of submitting a New Chemical Request Form
Basic Chemical Information

No abbreviations



Chemical Use & Storage






Peroxide Formers

GHS Hazards
Locate the GHS Hazard Identification section on your SDS (example below)GHS Hazard Identification

NFPA Hazard Identification
Locate the NFPA Diamond on your SDS (example below)NFPA Diamond






Safety Data Sheets

Wastes


This does not have to be your safety rep



Spill Response & Decontamination 



Misc.


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Contact Information