Title Page
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Project Name / No.
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Contractor
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Contractor's Contact No.
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Conducted by
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Date
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Site Address/Location
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Take or Attach Photo of Site
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Job Title
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Description of Work (overview list of planned activities)
Supervision of Task
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Click '+' and add personnel in charge of task supervision (e.g site supervisor, safety officer, foreman, etc.)
Employee
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Name
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Role
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Contact No.
Employees Involved
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Employee
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Name of personnel
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Role
Methodology
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In this section, provide step-by-step instruction as to how the work activity should be safely carried out and completed
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Sequence of Operations
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Plant & Equipment to be used
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Specific Staff Training
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Select the type of hazard associated with the planned activities below
Associated Hazard
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Hazard
- Working at heights/excavation
- Moving objects
- Slips, trips, and falls
- Material and manual handling
- Collapsing trenches
- Abestos
- Electricity
- Airborne fibers and materials
- Other
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Please specify
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Control Measures
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PPE (select the required ppe)
- Safety gloves
- Hearing Protection
- Eye Protection
- Respiratory Protection
- Coveralls
- Other
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Please specify
Emergency Procedures
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Name of Person with Health & Safety Responsibility
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Emergency Contact Details (include mobile no.)
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First Aid Provision - in the event of an emergency, the following procedures should be executed:
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Welfare Requirements
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Services to be Supplied by Others
Completion
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Other Information & Comments
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Prepared by (provide name & signature)
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Reviewed by (provide name & signature)
Method Statement Briefing Record
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Briefing delivered by
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Position
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Date
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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
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Name & Signature