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Safe Work Method Statement Summary Form - EDITABLE PDF

This document outlines a safe work method statement summary form. The form provides fields to identify the work details, hazards, required training or licenses, and control measures. It includes sections for emergency procedures, supervision requirements, and tasks with their associated risks and controls. Sign off is also included to confirm communication of the safe work method.

Uploaded by

Osama Hassan
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
37 views

Safe Work Method Statement Summary Form - EDITABLE PDF

This document outlines a safe work method statement summary form. The form provides fields to identify the work details, hazards, required training or licenses, and control measures. It includes sections for emergency procedures, supervision requirements, and tasks with their associated risks and controls. Sign off is also included to confirm communication of the safe work method.

Uploaded by

Osama Hassan
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 6

SAFE WORK METHOD STATEMENT SUMMARY FORM

INSTRUCTIONS
A Safe Work Method Statement (SWMS) is to be completed by competent personnel prior to a high risk job activity, which includes consultation with others completing
the work. All persons involved in works must have the SWMS explained and communicated to them prior to starting work and confirm that this has been completed.
Person Managing the Work Contact Details

Other PCBU’s at the Work Site Contact Details

Person Completing the SWMS Contact Details

Person Reviewing the SWMS Contact Details

Person Responsible for


Contact Details
Compliance with SWMS

Date SWMS Prepared Review Date

REVISIONS TO SWMS

Date Changes Made Made by Communicated To

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SAFE WORK METHOD STATEMENT SUMMARY FORM

WORK DETAILS

Location of Work

Scope of the work

What high risk work activities


are covered by this SWMS?

Who was consulted/involved in


preparing this SWMS?

References: Legislation,
Australian Standards, Codes of
Practice, MSDS & SOP’s

Plant and equipment involved in


the scope of work (must be
suitable and in good order)
What “high risk” licence classes,
tickets or permits are required
for the work?
What hazardous chemicals will
be used or on site? Safety data
sheets must be available.
What personal protective
equipment must be worn?

Tick relevant pictures and add any other PPE necessary for safe working

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SAFE WORK METHOD STATEMENT SUMMARY FORM
Other PPE:

Emergency and first aid


arrangements required for the
work?
Supervision arrangements for
inexperienced or young
workers?
Other Information Important to
Managing WHS for the Work?

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SAFE WORK METHOD STATEMENT SUMMARY FORM

SAFE WORK METHOD STATEMENT

Identify Task What High Risk Work is What are the WHS Hazards Describe the Control Measures Person Responsible for
(List these In Order) Involved? and Risks? (Use the Hierarchy of Control & as many controls Implementing &
as needed) Monitoring Controls

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SAFE WORK METHOD STATEMENT SUMMARY FORM
HAZARD AND RISK MANAGEMENT
Hierarchy of Control Examples of Controls
• Stop the activity / eliminate the risk HIGHEST LEVEL
Level 1: Elimination
• Change of process / methodology OF CONTROL

Level 2: Substitution • Use safer substance/chemicals

• Guards on power tools, use effective screens, barriers and edge protection
Level 2: Isolation
• Enclose noisy machinery, environmental swales, booms or barriers, washout station
• Use an Earth Leakage Device (safety switch) on electrical sources
Level 2: Engineering
• Use a machine to lift heavy objects, use scaffold rather than ladder as a platform
Level 3: • Change Work Practices and safe work method procedures
Administration • Tagging and testing procedures or Waste sorting
Level 3: Personal • Hard hats, glasses, hearing protection, hi-viz vests, safety boots/shoes LOWEST LEVEL
Protective Equipment • (PPE should be the last option to protect people) OF CONTROL

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SAFE WORK METHOD STATEMENT SUMMARY FORM

COMMUNICATION

By signing this record, I confirm that the SWMS above has been explained and I clearly understand. I confirm that any qualifications I need to undertake this activity are
current. I also clearly understand the controls in this SWMS must be applied as documented, otherwise work is to cease immediately.
Certificate, Licence
First Name Surname Work on Site Employed by Signature Date of Induction
(Number, Expiry Date)

Clear Form

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