S AFE W ORK M ETHOD S TATEMENT (SWMS)

A CTIVITY : SWMS #: P RINCIPAL C ONTRACTOR (PC):

COMPANY N AME : ABN: A DDRESS :

COMPANY A DDRESS : P ROJECT A DDRESS :

COMPANY C ONTACT : P HONE #: P ROJECT M ANAGER (PM): CONTACT PH. #:

SWMS A PPROVED BY E MPLOYER / PCBU / D IRECTO R / OWNER: D ATE SWMS PROVIDED TO PC:

NAME : PM S IGNATURE : DATE :

HIERARCHY OF CONTROLS M OST EFFECTIVE
S IGNATURE : DATE :

PERSON /S RESPONSIBLE FOR EN SURING COMPLIANCE WI TH SWMS:

PERSON /S RESPONSIBLE F OR REVIEWING THE SWMS:

RELEVANT WORKERS CONS ULTED IN THE DEVELOP MENT , APPROVAL AND COMMUNI CATION OF THIS SWMS:

NAME S IGNATURE DATE

L EAST EFFECTIVE
DETERMINE THE RISK SC ORE
RECORD RISK SCORE ON WORKSHEET (N OTE RISK SCORES HAVE NO A BSOLUTE VALUE AND SH OULD ONLY BE USED
CONSEQUENCE
FOR COMPARISON AND T O ENGENDER DISCUSSIO N .)
L IKELIHOOD INSIGNIFICANT MINOR M ODERATE M AJOR C ATASTROPHIC
A LMOST
3 H IGH 3 H IGH 4 A CUTE 4 A CUTE 4 A CUTE SCORE A CTION
CERTAIN
DO NOT PROCCED. REQUIRES IMMEDIATE AT TENTION . INTRODUCE FURTHER HIG H -LEVEL CONTROLS TO
L IKELY 2 MODERATE 3 H IGH 3 H IGH 4 A CUTE 4 A CUTE 4A: A CUTE
LOWER THE RISK LEVEL . R E -ASSESS BEFORE PROCEE DING .

R EVIEW BEFORE COMMENCING WO RK . INTRODUCE NEW CONTROL S AND /OR M AINTAIN HIGH - LEVEL CONTROLS
POSSIBLE 1 L OW 2 MODERATE 3 H IGH 4 A CUTE 4 A CUTE 3H: H IGH
TO LOWER THE RISK LE VEL . M ONITOR FREQUENTLY TO ENSURE CONTROL MEASU RES ARE WORKING .
2M: M AINTAIN CONTROL MEAS URES . P ROCEED WITH WORK . M ONITOR AND REVIEW RE GULARLY , AND IF ANY
UNLIKELY 1 L OW 1 L OW 2 M ODERATE 3 H IGH 4 A CUTE
M ODERATE EQUIPMENT /PEOPLE /MATERIALS /WORK PROCESSES OR PR OCEDURES CHANGE .

R ECORD AND MONITOR . P ROCEED WITH WORK . REVIEW REGULARLY , AND IF ANY
RARE 1 L OW 1 L OW 2 M ODERATE 3 H IGH 3 H IGH 1L: L OW
EQUIPMENT /PEOPLE /MATERIALS /WORK PROCESSES OR PR OCEDURES CHANGE .

REF: SWMS/ISRM ACTIVITY: AUTHORISED BY: REVIEW N O: DATE:

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SWMS SCOPE : E NVIRONMENT :

PERSONAL PROTECTIVE EQUIPMENT (PPE)

FOOT H EARING H IGH H EAD E YE FACE H AND P ROTECTIVE B REATHING SUN RINGS, WATCHES ,
P ROTECTION P ROTECTION V ISIBILITY P ROTECTION P ROTECTION P ROTECTION P ROTECTION C LOTHING P ROTECTION PROTECTION JEWELL ERY THAT MAY
BECOME ENTANGLED IN
MACHINES MUST NOT BE
WORN . L ONG AND LOOSE
HAIR MUST BE TIED BA CK .

T HIS WORK ACTIVITY IN VOLVES THE FOLLOWING IGH R ISK W ORK PLANNING & PREPARATION
CONFINED SPACES P RESSURISED GAS DISTR IBUTION MAINS OR PIP ING CHEMICAL , FUEL OR REFRIGERANT LINES ENERGISED ELEC TRICAL L IAISE WITH P RINCIPAL CONTRACTOR TO ESTABLISH THAT THE
M OBILE P LANT INSTALLATIONS OR SER VICES FOLLOWING ON - SITE SYSTEMS AND PRO CEDURES ARE IN PLACE :

DEMOLITION S TRUCTURES OR BUILDINGS INVOLVI NG STRUCTURAL ALTERA TIONS OR REPAIRS THA T REQUIRE TEMPORARY SUPPORT
- HEALTH AND S AFETY RULES - EMERGENCY
A SBESTOS TO PREVENT COLLAPSE
- INDUCTION FOR ALL WOR KERS MANAGEMENT
USING EXPLOSIVES W ORKING AT HEIGHTS GR EATER THAN 2 METRES , INCLUDING WORK ON TE LECOMMUNICATIONS TOW ERS
SITE SPECIFIC - HAZARD REPORTING
DIVING WORK W ORK IN AN AREA THAT MAY HAVE A CONTAMINA TED OR FLAMMABLE ATM OSPHERE - S UPERVISORY - PPE
A RTIFICIAL EXTREMES O F W ORKING AT DEPTHS GRE ATER THAN 1.5 M ETRES , INCLUDING TUNNELS OR MINES ARRANGEMENTS - EXCLUSION Z ONES
TEMPERATURE W ORK CARRIED OUT ADJA CENT TO A ROAD , RAILWAY OR SHIPPING LANE , TRAFFIC CORRIDOR - COMMUNICATION - RISK ASSESSMENTS
T ILT UP OR PRE -CAST CONCRETE IN OR NEAR WATER OR O THER LIQUID THAT INV OLVES RISK OF DROWNI NG
- INJURY REPORTING - SWMS AND S.

ALL PERSONS INVOLVED IN TASK MUST HAVE THIS SWMS COMMUNICATED TO THEM PRIOR TO WORK COMMENCING EMERGENCY R ESPONSE
Daily Tool Box Talks will be undertaken to identify, control, and communicate additional site hazard s. FOLLOW S ITE EMERGENCY P ROCEDURES AND THE DIRECTIONS O F
WARDENS AND FIRST AIDE RS .
Work must cease immediately if incident or near miss occurs. SWMS must be amended in consultation with relevant persons.
1. C ALL 000 (M OBILE 112)
Amendments must be approved by ______________ and communicated to all affected workers before work resumes. 2. S TATE TYPE AND SCALE OF EMERGENCY
SWMS must be made availa ble for inspection or review as required by WHS legislation. 3. S TATE WORKPLACE NAME AND LOCATION
4. NUMBER OF CASUALTIES IF APPLICABLE
Record of SWMS must be kept as required by WHS legislation (until job is complete or for 2 years if involved in a notifiable incident).
5. HAZARDS THAT MAY BE I NVOLVED SUCH AS CHEM ICALS OF FUEL
EMERGENCY EVACUATION PROCEDURE 6. S PECIFIC ACCESS POINT ON SITE E .G. STREET OR SIDE ENT RANCES
Rescue or Relocate people in immediate danger if you can do so without endangering yourself. 7. P ROVIDE CONTACT NAME AND PHONE NUMBER
R
8. A NSWER ALL QUESTIONS AND FOLLOW INSTRUCTI ONS GIVEN BY
A Sound the Alarm . E MERGENCY S ERVICES OPERATOR
9. DO NOT HANG UP UNTIL INSTRU CTED .
C Confin e the dangerous situation, fire, or hazardous material.
FIRST A ID K IT (FAK) Y ES NO
FIRE E XTINGU ISHER YES NO
E Evacuate the area on direction from the Site Manager or when it is unsafe to remain in the area.
SPILL K IT YES NO

REF: SWMS/ISRM ACTIVITY: AUTHORISED BY: REVIEW N O: DATE:

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 JOB STEP POTIENTIAL HAZARDS CONTROL MEASURES TO REDUCE RISK
NOTE: RISK -RATINGS AND P ERSON RESP ONSIBLE TO IMPLEMENT CONTROL MEASURES ARE RECORDED AT THE END OF EACH CONTROL SECT ION . INHERENT RISK - RATING (IR) R ESIDUAL R ISK - RATING (RR)
IR: RESPONSIBLE PERSON : RR:
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REF: SWMS/ISRM ACTIVITY: AUTHORISED BY: REVIEW N O: DATE:

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 SAFE WORK METHOD STATEMENT
This SWMS has been developed in consultation and cooperation with employee/workers and relevant Employer/Persons Conducting Business or Undertaking
(PCBU). I have read the above SWMS and I understand its contents. I confirm that I have the skills and training, including relevant c ertification to conduct the task as
described. I agree to comply with safety requirements within this SWMS including risk control measures, safe work instructions and Personal Protective Equipment
described.

OVERALL R ISK RATING AFTER

1 L OW 2 M ODERATE 3 H IGH 4 A CUTE
C ONTROLS
E MPLOYEE /W ORKER NAME J OB ROLE / POSITION SIGNATURE DATE T IME E MPLOYER /PCBU/ SUPERVISOR

REF: SWMS/ISRM ACTIVITY: AUTHORISED BY: REVIEW N O: DATE:

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