2561
2561
E-mail:
Project Name
Description of the
Task/Activity
Site Start
Address/Location: Date/Time:
Finish
Date/Time
Name Role/Trade
Personnel Involved
Key Materials
Specific Identified
Residual Hazards:
(or refer to the task
specific risk
assessment(s))
Specific Staff
Training
2.
3.
4.
Sequence of 5.
Operations:
(include sketches
if required) 6.
7.
8.
9.
10.
Hazardous
Substances:
(Attach MSDS if
Very Toxic Harmful/ Irritant Corrosive Dangerous Oxidising Highly Explosives
required) For the flammable
environment
Applicable: Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
Storage
Arrangements:
Details of Permits to
Work:
Other:
Required Personnel
Protective 1. Hi-Viz
Equipment:
2. Coveralls
Safety Boots Hard Hats Safety Gloves Hearing Eye Protection Respiratory
Protection Protection 3.
Emergency Procedures:
First Aid
First Aid Box Location:
Facilities:
Location of Nearest
Hospital:
Welfare Requirements
Services to be supplied by
Others
All work will be undertaken by qualified competent persons with experience of the type of work described
above, and in all cases in full accordance with safety procedures specified in the companies health and safety
Policy.
Prepared by:
Position: Date:
Reviewed by:
Position: Date:
Position:
Date:
We (the undersigned) have read and understood the attached method statement and will comply with the
specified requirements and control measures. If the work activity changes or deviates from that originally
envisaged, we will seek further advice and request an amended method statement.