Safe Work Method Statement

Project Name: Address:

Company Name: Activity/Trade:

Address: Office Contact No:
Supervisor Name: Contact No:

Person
Procedure (in steps) Possible Hazards Risk Control Measures
who will
(Break the job down into steps. Each (Identify the hazards associated with each Rating (Describe what action or procedure will be taken to eliminate or
step should accomplish some major step. Examine each to find possibilities that (See minimise the risk of injury or damage. Use the Hierarchy of ensure this
Controls below as a guide happens
task and be in logical sequence.) could lead to an accident or potential harm below)
arising.) 1. Eliminate the Hazard
2. Substitute the material or equipment
3. Isolate the hazard
4. Implement Engineering control
5. Implement Administrative control
6. PPE

E - Extreme Risk: The hazard has the potential to kill or permanently disable a person H - High Risk: The hazard has the potential to cause a LTI ≥ 7 days
M - Medium Risk: The hazard has the potential to cause a LTI < 7 days L - Low Risk: The hazard has the potential to cause a minor injury that will not disable a person (ie: Nil LTI)
Document Name: Version Page No.
817865709.doc 01 1 of 5
 Safe Work Method Statement

Person
Procedure (in steps) Possible Hazards Risk Control Measures
who will
(Break the job down into steps. Each (Identify the hazards associated with each Rating (Describe what action or procedure will be taken to eliminate or
step should accomplish some major step. Examine each to find possibilities that (See minimise the risk of injury or damage. Use the Hierarchy of ensure this
Controls below as a guide happens
task and be in logical sequence.) could lead to an accident or potential harm below)
arising.) 1. Eliminate the Hazard
2. Substitute the material or equipment
3. Isolate the hazard
4. Implement Engineering control
5. Implement Administrative control
6. PPE

E - Extreme Risk: The hazard has the potential to kill or permanently disable a person H - High Risk: The hazard has the potential to cause a LTI ≥ 7 days
M - Medium Risk: The hazard has the potential to cause a LTI < 7 days L - Low Risk: The hazard has the potential to cause a minor injury that will not disable a person (ie: Nil LTI)
Document Name: Version Page No.
817865709.doc 01 2 of 5
SAFETY FORM No: 2.6.15 Safe Work Method Statement

Personnel Summary
SUPERVISOR’S DETAILS
Supervisors Name & Qualifications: Name:
Experience:
Qualifications:
Supervisor’s Responsibilities:

In addition to the above, the supervisor is to provide training in the use of this SWMS, issue PPE and provide training in the same, supervise the
work, ensure conformity with this SWMS, amend the SWMS when additional hazards are found (and if applicable, ensure all workers receive a
tool-box talk to discuss the control measures for the additional hazards).

DESCRIPTION OF TRAINING THAT HAS BEEN GIVEN TO PEOPLE INVOLVED WITH THE WORK

H&S GENERAL INDUCTION: All workers must have successfully completed industry induction training

WORK ACTIVITY TRAINING: All workers need to have been trained in the activities outlined in this safe work method statement.

SITE INDUCTION: All workers are to be site inducted by the Principal Contractor, prior to commencing work on site.

OTHER: (List other training undertaken by workers): (eg: Confined Space, Manual Handling, Traffic Control etc)

TICKETS, PERMITS or LICENCES REQUIRED to undertake this work (ie. Certificates of Competency, Confined Spaces etc):

N.B. - Copies of the above must be shown to the Principal Contractor during site induction.

LEGISLATION, CODES OF PRACTICE and GUIDELINES applicable to this work

All work to comply with the location H&S Acts and Regulations and amendments, Workplace Injury Management & Workers Compensation Acts

Additional Codes and Standards applicable to this trade:

Document Name: Version Page No.

817865709.doc 01 3 of 5
 Safe Work Method Statement

Equipment & Material Summary

PLANT and EQUIPMENT USED and MAINTENANCE FREQUENCY :

Serial Plant/Equipment Contractor WorkCover Plant Hazards Maintenance/service records and log books sighted
Registration No identified and by Principle Contractor prior to equipment being
(if applicable) controlled within used on site?
SWMS?
Yes No Sign Date

1
2
3

ELECTRICAL EQUIPMENT USED DURING THE WORKS (Attach Electrical Equipment Register if applicable):
Item Tag/Item Testers Name & Signature License Number Test Date Result Test Date Result
Number
____ /____ /____ ____ /____ /____
____ /____ /____ ____ /____ /____
HAZARDOUS SUBSTANCES or DANGEROUS GOODS USED IN THE WORKS and anticipated volumes (Attach MSDS if applicable):
MSDS
Purpose Location & Volume Used Controls
Date on Site Date Left Site Product Name MSDS Date Attached
(ie. Application on site) on Site (& PPE to be worn)
(Y/N)
/ / / / / /

/ / / / / /

/ / / / / /
N.B. - All workers must be trained in the safe use of all chemicals and provided with the PPE required when using and storing these chemicals. Disposal is to be as per the waste disposal methods
in the MSDS. Spillage and leaks are to be cleaned up as per the spill/leak procedures identified in the MSDS.

Document Name: Version Page No.

817865709.doc 01 4 of 5
 Safe Work Method Statement

We agree that we have been consulted in the hazards and control measures and agree to complete the work in accordance with our Safe Work
Method Statement (SWMS).
We have been provided with training in all tasks outlined in our SWMS and in the Codes of Practice applicable to our work.

Employee / Worker Signature Date Employee / Worker Signature Date

1. / / 8. / /
2. / / 9. / /
3. / / 10. / /
4. / / 11. / /
5. / / 12. / /
6. / / 13. / /

Reviewed by: Signature: Date:

(Principal Contractor’s Representative)

Any changes, additions or deletions made to this SWMS are to be covered with the above personnel and the Principal Contractors representative at a
Toolbox meeting (Record date and time of Toolbox meeting below):

Date: Time:
Comments:

A copy of the Toolbox Meeting must be attached to this SWMS.

Document Name: Version Page No.

817865709.doc 01 5 of 5