Title Page

  • Project Name / No.

  • Contractor

  • Contractor's Contact No.

  • Conducted by

  • Date

  • Site Address/Location
  • Take or Attach Photo of Site

  • Job Title

  • Description of Work (overview list of planned activities)

Supervision of Task

  • Click '+' and add personnel in charge of task supervision (e.g site supervisor, safety officer, foreman, etc.)

  • Employee
  • Name

  • Role

  • Contact No.

Employees Involved

    Employee
  • Name of personnel

  • Role

Methodology

  • In this section, provide step-by-step instruction as to how the work activity should be safely carried out and completed

  • Sequence of Operations

  • Plant & Equipment to be used

  • Specific Staff Training

  • Select the type of hazard associated with the planned activities below

  • Associated Hazard
  • Hazard

  • Please specify

  • Control Measures

  • PPE (select the required ppe)

  • Please specify

Emergency Procedures

  • Name of Person with Health & Safety Responsibility

  • Emergency Contact Details (include mobile no.)

  • First Aid Provision - in the event of an emergency, the following procedures should be executed:

  • Welfare Requirements

  • Services to be Supplied by Others

Completion

  • Other Information & Comments

  • Prepared by (provide name & signature)

  • Reviewed by (provide name & signature)

Method Statement Briefing Record

  • Briefing delivered by

  • Position

  • Date

  • We (the undersigned) have read and understood the attached method statement and will comply with the specified requirements and control measures. If the work activity changes or deviates from that originally envisaged, we will seek further advice and request an amended method statement.

  • Employee
  • Name & Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.