JSAF - Job Safety Assessment Form Department of Chemical...

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August, 2004 Rev. 1 1 Job Safety Assessment Form Department of Chemical Engineering Michigan Technological University Equipment Name : JSA Author: Room Number/Building : Faculty Supervisor: Revision # : Revision Date : Purpose of Experiment / Equipment: Briefly describe what this experiment is designed to achieve and the types of data collected. Personal Protective Equipment (PPE) Check all PPE worn during the entire experiment. Do not list these in the procedure section. Long Pants Safety Glasses Hard Hat Apron Long Sleeves Splash Goggles Insulated Gloves Ear Protection Non-porous Shoes Face Shield Chemical Gloves Other: Hazard Summary – Check all general hazards that are likely to be encountered during this experiment and list the major source of the hazard. Hazard Major Source of Hazard Toxicity Fire/Flammability Reactivity Pressure Hazard Electrical Shock Mechanical Hazard Hot Surfaces/ High Temp > 150 F Biohazard Laser Radiation Ionizing radiation Other: Other: Expected Operating Conditions – Temperature Pressure Normal: Normal: Minimum: Minimum: Maximum: Maximum:
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