JSA

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Safe Work Method Statement -
  
  This document is to be used by property management personnel or contractors undertaking repairs to buildings and other associated repairs to equipment and plant on the school campus

General Information

• Company Name

• Company Address
  Address

• Yes

  No

  N/A

• Name of Responsible Person

• Commencement Date

  Date

• Signature

  Sign

Task Information

• Description of the work?

• Specific work location?
  Address

• What are the hazards associated with the work?

  Select Working at height Objects falling from height Slips, trips and falls Moving parts Protruding objects Using chemicals Moving vehicles Hot or cold surfaces Manual handling Collapsing Overturning Electricity Environmental Contamination Fumes or dusts Flying particles Fire or flammable atmospheres Bursting, explosion, over pressure Vibration Noise UV Radiation Oxygen Enrichment Asphyxiation Drowning Adverse weather Faulty equipment Hot works Confined spaces Health issues Sharp objects Overhead loads Working alone Shattering objects Poor lighting

  • Working at height
  • Objects falling from height
  • Slips, trips and falls
  • Moving parts
  • Protruding objects
  • Using chemicals
  • Moving vehicles
  • Hot or cold surfaces
  • Manual handling
  • Collapsing
  • Overturning
  • Electricity
  • Environmental Contamination
  • Fumes or dusts
  • Flying particles
  • Fire or flammable atmospheres
  • Bursting, explosion, over pressure
  • Vibration
  • Noise
  • UV Radiation
  • Oxygen Enrichment
  • Asphyxiation
  • Drowning
  • Adverse weather
  • Faulty equipment
  • Hot works
  • Confined spaces
  • Health issues
  • Sharp objects
  • Overhead loads
  • Working alone
  • Shattering objects
  • Poor lighting

• Take photo's of any major hazards

  Media

• Select the general control measures for the task here

  Select Certified plant and equipment Tested and tagged equipment Equipment checked before use Certified height safety equipment Rated anchor points Moving parts guarded Edge protection Lifting to own capacity Good lifting techniques Isolation of services Good housekeeping Fire checks Purging or ventilation Dust extraction Waste chemical or substance containment Correct slinging of loads Chemicals correctly stored and labelled Chemicals used according to instructions Area sealed off Safety signage posted Equipment secured

  • Certified plant and equipment
  • Tested and tagged equipment
  • Equipment checked before use
  • Certified height safety equipment
  • Rated anchor points
  • Moving parts guarded
  • Edge protection
  • Lifting to own capacity
  • Good lifting techniques
  • Isolation of services
  • Good housekeeping
  • Fire checks
  • Purging or ventilation
  • Dust extraction
  • Waste chemical or substance containment
  • Correct slinging of loads
  • Chemicals correctly stored and labelled
  • Chemicals used according to instructions
  • Area sealed off
  • Safety signage posted
  • Equipment secured

• List all site specific control measures here?

• Select the plant and equipment required for the task?

  Select Scaffolding Ladders (3 points of contact) Forklift Elevated Work Platform Power Tools Hand Tools Ventilation/Extraction equipment Crane and Hiabs Spraying Equipment Crawler Boards Harnesses Lanyards/Inertia Reels/Karabiners Certified Anchor Point(s) Slings Suction Cups Extension Leads/Multiplugs RCD's Tractors Compressor Mowers Quad Bikes Cones, Barriers, Warning Tape Chainsaw Weed Eater Compressor Gas Powered Nail Gun Edge Protection

  • Scaffolding
  • Ladders (3 points of contact)
  • Forklift
  • Elevated Work Platform
  • Power Tools
  • Hand Tools
  • Ventilation/Extraction equipment
  • Crane and Hiabs
  • Spraying Equipment
  • Crawler Boards
  • Harnesses
  • Lanyards/Inertia Reels/Karabiners
  • Certified Anchor Point(s)
  • Slings
  • Suction Cups
  • Extension Leads/Multiplugs
  • RCD's
  • Tractors Compressor
  • Mowers
  • Quad Bikes
  • Cones, Barriers, Warning Tape
  • Chainsaw
  • Weed Eater
  • Compressor
  • Gas Powered Nail Gun
  • Edge Protection

• Take pictures of certified plant labels here

  Media

• Select the personal protective equipment (PPE) required for the task?

  Select Hard Hat Gloves Respirator Dust Mask Overalls Wet Weather Gear Hearing Protection Safety Glasses Safety Goggles Safety Visor Hi Vis Vest Chainsaw Chaps Safety Footwear Thermal Clothing Harness Life Jacket Sun Hat/Sunscreen

  • Hard Hat
  • Gloves
  • Respirator
  • Dust Mask
  • Overalls
  • Wet Weather Gear
  • Hearing Protection
  • Safety Glasses
  • Safety Goggles
  • Safety Visor
  • Hi Vis Vest
  • Chainsaw Chaps
  • Safety Footwear
  • Thermal Clothing
  • Harness
  • Life Jacket
  • Sun Hat/Sunscreen

Permits

• Select the permits required for the task here?

  Select Hot Work Confined Space Asbestos Working at Height

  • Hot Work
  • Confined Space
  • Asbestos
  • Working at Height

Photo's

• Add photo's to show how the area/task has been made safe before work commences

  Media

Briefing and Acknowledgement

• I hereby confirm that I have been briefed on the above information and will comply with all the controls listed in the Safety Work Method Statement

• Person(s) undertaking the work please sign here

Signature(s)

• Signature

  Sign

• Date

  Date