FORM 4.

0 METHOD STATEMENT

FORM 4.0 METHOD STATEMENT REVISION:

PART A CONTRACTOR DETAILS
COMPANY NAME

CONTACT NAME

ADDRESS

PHONE
EMAIL

PART B PROJECT DETAILS

PROJECT TITLE

SITE ADDRESS

DESCRIPTION OF TASK / ACTIVITY

PSCS ADDRESS

START DATE:

END DATE:

START TIME:

END TIME:

PART C PERSONNEL INVOLVED

NAME

ROLE / TRADE

SITE SUPERVISOR

PHONE:

EMAIL:

SAFETY OFFICER / ADVISOR

PHONE:

EMAIL:

PART D EQUIPMENT REQUIRED

KEY PLANT & TOOLS (ATTACH CERTIFICATION IF APPLICABLE)

KEY MATERIALS

OTHER ESSENTIAL EQUIPMENT

PART E SAFETY

SPECIFIC RESIDUAL IDENTIFIED HAZARDS (OR REFER TO THE TASK SPECIFIC RISK ASSESSMENTS)

SPECIFIC STAFF TRAINING (E.G. CSCS)

SEQUENCE OF OPERATIONS (INCLUDE SKETCHES IF REQUIRED)

DETAILS OF COORDINATION / INTERACTION REQUIRED WITH PROJECT SUPERVISORS, CONTRACTORS AND

OTHERS

TEMPORARY WORKS NEEDED TO FACILITATE THE PERMANENT WORKS (IF NONE, STATE NONE)

FALL PROTECTION MEASURES (WHERE WORK AT HEIGHT CANNOT BE ELIMINATED CONSIDER BOTH
PERSONNEL AND MATERIALS)

SAFE WORKING LOADS (SWLS) DETAIL ANY LIMITS ON THE LOADING APPLICABLE TO TEMPORARY
PLANT/EQUIPMENT OR FIXED ELEMENTS OF THE STRUCTURE WHERE THE WORK IS TAKING PLACE
DETAIL PERMITS TO WORK (IF APPLICABLE)
UTILITY / POWER SHUT DOWN REQUIRED?

REQUIRED PERSONAL PROTECTIVE EQUIPMENT (PPE)

SAFETY BOOTS

YES

NO

HARD HATS

YES

NO

SAFETY
GLOVES
YES

OTHER PPE REQUIRED (PLEASE STATE)

SERVICES TO BE SUPPLIED BY OTHERS
OTHER INFORMATION AND COMMENTS

NO

HEARING
PROTECTION
YES

NO

EYE
PROTECTION
YES

NO

RESPIRATORY
PROTECTION
YES

NO

HI-VIZ
YES

NO

PART F HAZARDOUS SUBSTANCES

ATTACH CHEMICAL RISK ASSESSMENTS IF REQUIRED
LIST HAZARDOUS SUBSTANCES & IDENTIFY RISKS BELOW

OX
CO
IDISING
MPRESSD
LIQUIDS GASES

EXPLOSIVES FLAMMABLE
LIQUIDS

YES

NO

YES

NO

YES

NO

YES

NO

CO
AC
SKI
RROSIVE UTE TOXICITY N IRRITATION

AS
HAZ
ARDOUS TO
PIRATION
THE AQUATIC
HAZARD
ENVIRONMENT

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

STORAGE ARRANGEMENTS

PART G EMERGENCY PROCEDURES & WELFARE

REQUIREMENTS
FIRST-AID FACILITIES
NAME OF FIRST AIDER

PHONE

FIRST-AID BOX LOCATION

LOCATION OF NEAREST HOSPITAL
WELFARE REQUIREMENTS
DECLARATION
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 COMPANYS HEALTH AND SAFETY POLICY
PREPARED BY
NAME
SIGNATURE
DATE
REVIEWED BY
NAME

SIGNATURE

DATE

PART H ITEMS ATTACHED

SKETCHES
YES

NO

CERTIFICATION OF
PROGRAMME OF
PLANT, ETC.
WORK
YES
NO
YES
NO

RISK ASSESSMENTS
YES

NO

TRAINING RECORDS
YES

NO

INFORMATION SUPPLIED PREVIOUSLY

PART J METHOD STATEMENT BRIEFING RECORD

BRIEFING DELIVERED BY
NAME

SIGNATURE

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
DATE