Description of Work (overview list of planned activities)
Supervision of Task
Click '+' and add personnel in charge of task supervision (e.g site supervisor, safety officer, foreman, etc.)
Name of personnel
In this section, provide step-by-step instruction as to how the work activity should be safely carried out and completed
Sequence of Operations
Plant & Equipment to be used
Specific Staff Training
Select the type of hazard associated with the planned activities below
PPE (select the required ppe)
Name of Person with Health & Safety Responsibility
Emergency Contact Details (include mobile no.)
First Aid Provision - in the event of an emergency, the following procedures should be executed:
Services to be Supplied by Others
Other Information & Comments
Prepared by (provide name & signature)
Reviewed by (provide name & signature)
Method Statement Briefing Record
Briefing delivered by
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.
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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