Method Statement

Promoter: Engineer: Main Contractor: Contact Person/s: Tel:

E-mail:

Project Name Document Number

Description of the Issue No.: 00 Date: 16/11/2010

Task/Activity Rev.No. : Date:
Site Address/Location: Start
Date/Time
Finish
Date/Time
Name Role/Trade

Personnel Involved

Site Supervisor:
Tel:
Safety Officer:
Tel:
Key Plant / Tools /
Equipments
(Attach Certification)

Key Materials Material Specification Handling & Storage

(Materials Accepted by Instruction/s
Quality) – Attach
1. Inspection
Certificate –Material
& Dimensional
2. Functional Test
Certificate
3. Compliance
Statement

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 Method Statement
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Other Essential (i.e. access platforms/winches/ladders, etc)

Equipment/s:

Specific Identified
Residual Hazards:
(or refer to the task
specific risk
assessment(s))

Specific Staff Training

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 Method Statement
Promoter: Engineer: Main Contractor: Contact Person/s: Tel:

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*Sequence of Operations:(include sketches if *Inspection & Testing - Instructions *Safety – Precautions

required) - *To be prepared only by the Process Owner *To be prepared only by the Process Owner – *To be prepared only by the Process Owner –
– Site Engineer (Flow Diagram is Quality Engineer Safety Engineer
preferable)
1. 1.
1.
2. 2.
2.
3. 3.
3.
4. 4.
4.
5. 5.
5.
6. 6.
6.
7. 7.
7.
8. 8.
8.
9. 9.
9.
10. 10.
10.
Temporary
Supports and
Props needed
to facilitate the
works:
Method of (i.e. Ladders/MEWPS/Scaffold/Trestles/Step Ladder/ Power elevated work platform, etc)
Access and
Egress to the
work area:
Fall Protection (i.e. Guard Rails/Toe Boards/Brick Guard/Safety Harnesses/Exclusion Zones, etc.)
Measures:
(Where work at
height cannot be
eliminated –
consider both
Personnel &
Materials)

Hazardous
Substances:
(Attach MSDS
if required)
Very Toxic Harmful/ Irritant Corrosive Dangerous Oxidising Highly flammable Explosives
For the
environment
Applicable: Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

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 Method Statement
Promoter: Engineer: Main Contractor: Contact Person/s: Tel:

E-mail:

Special
Storage
Arrangements

Details of
Permits to
Work:
SWL’s: (Detail any limits on the loadings applicable to temporary plant/equipment or fixed elements of the structure where the work is taking place)

Required Other:
Personnel
Protective 1. Hi-Viz
Equipment:
Safety Boots Hard Hats Safety Gloves Eye Protection 2. Coveralls
Hearing Respiratory Protection
Protection
Emergency Procedures:

Name of On-Site Contact Number:

First Aider:
First Aid Box
First Aid
Location:
Facilities:
Location of Contact Number
Nearest
Hospital:
Welfare Requirements Contact info. of the Welfare Officer

Services to be supplied by
Others

Other information &

Comments

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 Health and Safety Plan and applicable legal requirements.

Prepared by: Date:

Position:

Reviewed by: Date:

Position:
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 Method Statement
Promoter: Engineer: Main Contractor: Contact Person/s: Tel:

E-mail:

Items Attached: Yes No Remarks

Sketches
 
Certification of Plant etc.
 
Programme of Work
 
Inspection & Test Certificates
 
Compliance Statement
 
Special Process Validation
 
Risk Assessments
 
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 (Print) Signature Date

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 Method Statement
Promoter: Engineer: Main Contractor: Contact Person/s: Tel:

E-mail:

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