Safe Work Method Statement Template (docx

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No. DEE ESWB-24-2-2
Authorised By: Manager ESWB
Title: Safe Work Method Statement
Page Number: 1 of 2
Issue Date: September 2012
Last Reviewed: June 2013
CENTRAL OFFICE USE ONLY
Next Review Date: June 2015
Is a Permit to Work Required?
Personal Protective Equipment (PPE)
Requirements:
(please indicate by ticking or blacking-out
box)
None
Confined Space
Hot Work
Work at Height
(please list)
Tools, Equipment or Instruction Required
(consider such things as gas detection, ventilation fans, lighting,
scaffolding, etc)
Destructive
or
Asbestos
Based
Work
Hazardous Materials
Potential Environmental Hazards
(List any hazardous materials to be used)
(please indicate by ticking box)
Fire/Emergency Equipment
Requirements
(consider fire extinguishers, rescue gear, etc)
Spills to ground
Noise pollution
Soil erosion
Spills to water
Hazard to flora or
fauna
STEP/TASK
No.
Air pollution (dust, fumes)
Job Step/Task
Potential Hazard
Current Control
Describe the steps required to
perform the task in the sequence they
are carried out
Against each step list the potential
hazards that could cause
injury/damage when the task step is
performed.
List the control measure required to
eliminate or minimise the risk of
injury arising from the identified
hazard
THIS DOCUMENT IS UNCONTROLLED WHEN PRINTED
Action Plan
(additional Controls)
Responsibility
No. DEE ESWB-24-2-2
Authorised By: Manager ESWB
Title: Safe Work Method Statement
Page Number: 2 of 2
Issue Date: September 2012
Last Reviewed: June 2013
CENTRAL OFFICE USE ONLY
Next Review Date: June 2015
4. SWMS Signoff
Authorised By:
Signature:
THIS DOCUMENT IS UNCONTROLLED WHEN PRINTED
Date:
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