SAMMS Template

• Conducted on

  Date
• Location
  Address

• Prepared by

• Personnel on Site

Does your work involve any of the following Safe Work Method Statements (SWMS)?

• Confined Spaces Entry

  Yes

  No

• Complete HS-FRM-006 Confined Spaces Entry Permit

• Is isolation (lockout/tagout) required?

  Yes

  No

• Complete HS-FRM-021 Electrical Hazard Preventative Actions Checklist

• Trenching and Excavation

  Yes

  No

• Complete HS-FRM-003 Permit To Excavate

• Working Near Live Services

  Yes

  No

• Complete HS-FRM-011 Overhead Wire Assessment and Dial Before You Dig plans are on site and understood

• Working at Heights Greater than 2m

  Yes

  No

• Complete Working At Heights Permit Ect

• Movement of Powered Mobile Plant

  Yes

  No

• Complete Vehicle movement Plan

• Working On or Adjacent to Roads

  Yes

  No

• Ensure Traffic Management Plan is in place Ect

• Demolition

  Yes

  No

• Complete HS-FRM-018 Demolition Safety Checklist

• Working On or Adjacent to Rail

  Yes

  No

• Ensure rail permit is completed and adhered to

• Working In, Over ar Adjacent to Water

  Yes

  No

• Complete HS-FRM-013 Working In, On, Over or Adjacent to Water Checklist

• Non Friable Asbestos Removal

  Yes

  No

• Complete HS-FRM-020 - Asbestos Removal Control Plan Template

• Working Near Energised Electrical Installations

  Yes

  No

• Complete HS-FRM-021 Electrical Hazard Preventative Actions Checklist

Are any of the following supplementary safety requirements needed?

• Is work being conducted near Overhead Powerlines/Communications assets?

  Yes

  No

• Complete HS-FRM-011 Overhead Wire Assessment

• Hot Work Permit

  Yes

  No

• Complete HS-FRM-024 Hot Work Permit

• Lifting Operations by Mechanical Means

  Yes

  No

• Complete HS-FRM-014 Lifting Operations Checklist

Site Specific Photos

• Photos of site

  Media

• Task Supervisor

  Sign

• Team Member

  Sign

• Complete JSEA

• Complete JSEA