Inspection
Take or Attach Photo of Site
Job Title
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
Role
Contact No.
Employees Involved
Name of personnel
Role
Methodology
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
Hazard
Please specify
Control Measures
PPE (select the required ppe)
Please specify
Emergency Procedures
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:
Welfare Requirements
Services to be Supplied by Others
Completion
Other Information & Comments
Prepared by (provide name & signature)
Reviewed by (provide name & signature)
Method Statement Briefing Record
Briefing delivered by
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.
Name & Signature
