Safe Work Method Statement

• Process

• Conducted on

  Date

• Prepared by

• Document Id

• Worksite

  The Cube

  Other

• Review Date

  Date

• This Safe Work Method Statement has been produced for your information and safety. This should be reviewed and understood prior to carrying out work activity

• Use Risk Matrix to calculate Risk Rating

  
Step

• Critical Step Description

• Potential Hazards

• Uncontrolled Risk Rating

  Low

  Medium

  Significant

  High

  Extreme

• Safety Control Measures

• Controlled Risk Rating

  Low

  Medium

  Significant

  High

  Extreme

Training

• Training and Licenses

  Select CoW OHS Induction Work Activity Induction Site Induction Manual Handling Other Construction Induction (White Card) High Risk Work License

  • CoW OHS Induction
  • Work Activity Induction
  • Site Induction
  • Manual Handling
  • Other
  • Construction Induction (White Card)
  • High Risk Work License

PPE

• Is PPE Required?

  Yes

  No

  Optional

• Type

  Select Gloves Safety Boots Protective Headwear Eye Protection Hearing Protection Protective Clothing Face Protection

  • Gloves
  • Safety Boots
  • Protective Headwear
  • Eye Protection
  • Hearing Protection
  • Protective Clothing
  • Face Protection

• Type

  Select Gloves Safety Boots Protective Headwear Eye Protection Hearing Protection Protective Clothing Face Protection

  • Gloves
  • Safety Boots
  • Protective Headwear
  • Eye Protection
  • Hearing Protection
  • Protective Clothing
  • Face Protection

Plant and Equipment

• Plant and Equipment Required

  Select EWP Hand Tools Ladder Manual Handling Aids Power Tools Other

  • EWP
  • Hand Tools
  • Ladder
  • Manual Handling Aids
  • Power Tools
  • Other

• Equipment Maintenance Checks

• Engineering Certificates/Permits/Approvals Required

Sign Off

• I have read and understood the above Safe Work Method Statement and will conduct work accordingly

  Sign

Persons Responsible for Supervising Work

• Name

  Sign

• Postion