Safe Work Method Template (Blank) - Facilities Management

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YOUR COMPANY LOGO
Company address
SAFE WORK METHOD STATEMENT (SWMS)
Date:
For: Insert type of SWMS
Address of
Works
Work includes High Risk Work Activity - Yes / No
Activity: Describe
Bus Phone:
Mobile
Contact:
Work Method Statement
No:
ABN #
Authorised by:
Date of last modification:
Version:
Prepared by:
Position:
Training required for contractor staff to undertake this job or activity:
Training records located where:
Mandatory: Construction industry Induction (White Card)
Engineering or Certificates of Competencies, Permits or Approvals required to undertake this activity:
List major items of plant or equipment
Required equipment checks prior to or during this activity:
PPE required for this activity:
Other Specific PPE:




Persons responsible for supervising work on the job:
Name:
Position:
Date
Name:
Position:
Date
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Job Steps
Hazards/Risks
Initial Risk
score
Refer Risk
Matrix
Major steps /events in the work
process
What could go wrong? List the
hazards or risks that workers and
environment are exposed to during this
stage of the work e.g.: falling from roof
edge while cleaning gutters
What is
starting risk
score?
Control Measures
Control measures to be selected and applied using the
Hierarchy of Control –
1. Elimination -2. Substitution -3.Engineering (preferred )
4. Admin -5 PPE
What will be done on this site by the workers
or the contractor to control this particular safety
or environmental hazard or risk.eg:
 Use QUT roof safety anchorage
system &
 only height trained staff can work on
roofs
 Obtain roof access permit from FM
.
Responsibility
for Control
Residual
Risk
Score
Refer Risk
Matrix
Contractor
name
After
controls
are in
place ,
what is the
risk now?
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Control Monitoring
How will the stated controls on the job be monitored to ensure that they are in place and effective??
E.g.: site supervisor presence on site at all times; weekly inspections of scaffolding; on the job safety observations by contractor
Legislative Compliance:List all legislation pertaining to the works being under taken – e.g. 1. 2011 Workplace Health and Safety Act
2. 2011 Workplace Health and Safety Regulations
 S299– PCBUs’ obligation to prepare work method statement
before starting high risk construction work
 S291– Meaning of High Risk Construction Work
 Part 4.5 – High Risk Work ( Licensing)
3. QLD Code of Practice -Plant
4. Other relevant H & S Codes of Practice and Industry Guidelines
5. 2002 Electrical Safety Act & Regulations & Codes of Practice
6. Environmental Protection Act 1994
 Environmental Protection Regulation 2008
 Environmental Protection (Noise) Policy 2008
7. National Environment Protection Council (Queensland) Act 1994
8. AS4360-2004 Risk Management
9. Other relevant AS/NZ Standards
Safe Work Method Statement - Work Team Sign-on/ Review Register
Personnel are required to sign this register to indicate they have read, understand and will work to the requirements of the SWMS
This SWMS covers:
Name
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SWMS No:
Employee Signature
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Name
Employee Signature
Date
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Risk Rating Matrix
Consequences
Personal Harm
Criteria
Likelihood
Probability:
Is expected to
occur in most
circumstances
Will probably
occur
Might occur at
some time in
the future
Could occur but
doubtful
May occur but
only in
exceptional
circumstances
Injuries or ailments
not requiring
medical treatment.
Minor injury or
First Aid
Treatment.
Serious injury
causing
hospitalisation or
multiple medical
treatment cases.
Life threatening
injury or multiple
serious injuries
causing
hospitalisation.
Death or multiple
life threatening
injuries.
Insignificant
Minor
Moderate
Major
Catastrophic
1
2
3
4
5
5
Almost Certain
M (9)
H (16)
E (22)
E (24)
E (25)
4
Likely
M (6)
M (13)
H (19)
E (21)
E (23)
3
Possible
L (4)
M (11)
H (15)
H (18)
E (20)
2
Unlikely
L (2)
M (7)
M (12)
M (14)
H (17)
1
Rare
L (1)
L (3)
L (5)
M (8)
M 10)
(*** The above matrix has been developed from Australian Standard 4360-2004 Risk Management ***)
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