JOB/TASK NAME:
PAGE____OF____
DATE:
NEW
REVISED
EMPLOYEE(S)/POSITION(S) PERFORMING THE JOB:
SUPERVISOR(S):
ANALYSIS BY:
PLANT/LOCATION:
DEPARTMENT(S):
SHIFT
(if applicable)
:
APPROVED BY:
PERSONAL PROTECTIVE EQUIPMENT:
TRAINING REQUIREMENTS:
JOB STEPS POTENTIAL HAZARDS ACTION/PROCEDURE TO CONTROL OR ELIMINATE
1
2
3
4
5
Job Safety Analysis Form
Toilet Bowl Cleaner
1
1
Dec. 13, 2016
Custodial Employees
Lead Custodian
Custodial Dept.
SUU
Custodial
N/A
Ralph Savage
Closed toe shoes, gloves, eye wear
Safe Custodial Practices Video, Hands-on training, following instructions
Prepare the cleaning area by: Clearing
area, flushing toilets, and plunging toilets
to remove as much water as possible
Slipping, splashes, spills, skin irritation
Place closed for cleaning signs/caution floor
wet signs, wear proper PPE
Apply cleaner directly to porcelain of
inner bowl
Slipping, splashes, spills, skin irritation
Wear proper PPE, close chemical lid after
application, never place chemical container on
counter tops or other non chemical resistant surfaces
Allow chemical to dwell, then scrub
using bowl mop or bell brush
Slipping, splashes, spills, skin irritation
Wear proper PPE, follow correct application
and scrubbing procedures as taught in
hands-on training
Rinse and flush
Slipping, splashes, spills, skin irritation
Wear proper PPE, follow correct application
and scrubbing procedures as taught in
hands-on training
Remove PPE, wash hands and arms
with soap and water
0
JOB/TASK NAME:
Fill in the name of the job or task being analyzed
PAGE____OF____
Indicate what page of the
form this is
DATE:
Fill in the date
here
NEW
REVISED
EMPLOYEE(S)/POSITION(S) PERFORMING THE JOB:
Fill in the applicable name(s)/position(s) performing the job
SUPERVISOR(S):
Put the names of the supervisor
on the job
ANALYSIS BY:
Indicate name of person/group
performing the JSA
PLANT/LOCATION:
Indicate the name and location
DEPARTMENT(S):
Indicate name of department(s) in which job is
performed
SHIFT
(if applicable)
:
Fill in the shift the job is
performed on, if applicable
APPROVED BY:
Indicate the name of person who
approves JSA
PERSONAL PROTECTIVE EQUIPMENT:
Indicate PPE required to be used when performing this job
TRAINING REQUIREMENTS:
Indicate what safety trainings need to be completed before performing this job
JOB STEPS POTENTIAL HAZARDS ACTION/PROCEDURE TO CONTROL OR ELIMINATE
1
Fill in potential hazards associated with this step
Fill in any actions or procedures that can be used to
control or eliminate this hazard
2
Job Safety Analysis Form