"Safe Work Method Statement Template"

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Safe Work Method Statement (SWMS)
Page 1 of 4
This SWMS template is provided as a guide for contractors to use when developing a SWMS for
the activities undertaken by the business.
1.
Organisation details
Company name
ABN
Contact name
Business address
Phone
State
Postcode
Email
2.
Activity details
Activity/task
Is the task High Risk
Yes
Please specify
described by SWMS
Construction Work?
No
Site address
MITM description
MITM number
SWMS date
Version
State
Postcode
3.
SWMS preparation
Name of person who prepared
Date prepared
SWMS
Names of workers who have had input
into the development of this SWMS
Name of person responsible for implementation, review and monitoring of this SWMS
4.
Minimum Personal Protective Equipment requirements
PPE
Yes No
PPE
Yes No
PPE
Yes No
PPE
Yes No
PPE
Yes No
Long sleeve/Long pants
Protective gloves
Hard hat
Half face respirator
Tyvek suit
Safety boots
Face shield
Hearing protection
Full face respirator
Gattors
Safety glasses
High-vis vest
Disposable dust mask
SCBA
Other
5.
Hazardous substances and/or dangerous goods required for activity
Attach copies of Material Safety Data Sheets (MSDS)
-
Product name
MSDS attached
Quantity (Kg/L)
Product name
MSDS attached
Quantity (Kg/L)
Yes
No
Yes
No
Yes
No
Yes
No
Safe Work Method Statement (SWMS)
Page 1 of 4
This SWMS template is provided as a guide for contractors to use when developing a SWMS for
the activities undertaken by the business.
1.
Organisation details
Company name
ABN
Contact name
Business address
Phone
State
Postcode
Email
2.
Activity details
Activity/task
Is the task High Risk
Yes
Please specify
described by SWMS
Construction Work?
No
Site address
MITM description
MITM number
SWMS date
Version
State
Postcode
3.
SWMS preparation
Name of person who prepared
Date prepared
SWMS
Names of workers who have had input
into the development of this SWMS
Name of person responsible for implementation, review and monitoring of this SWMS
4.
Minimum Personal Protective Equipment requirements
PPE
Yes No
PPE
Yes No
PPE
Yes No
PPE
Yes No
PPE
Yes No
Long sleeve/Long pants
Protective gloves
Hard hat
Half face respirator
Tyvek suit
Safety boots
Face shield
Hearing protection
Full face respirator
Gattors
Safety glasses
High-vis vest
Disposable dust mask
SCBA
Other
5.
Hazardous substances and/or dangerous goods required for activity
Attach copies of Material Safety Data Sheets (MSDS)
-
Product name
MSDS attached
Quantity (Kg/L)
Product name
MSDS attached
Quantity (Kg/L)
Yes
No
Yes
No
Yes
No
Yes
No
Safe Work Method Statement (SWMS)
Page 2 of 4
6.
Plant and equipment utilised (tick or add as applicable) –
Attach evidence to this SWMS
Item (including all mechanical and electrical items) List inspections and maintenance requirements and attach evidence to this SWMS
Is a licence/ticket
Note: All servicing MUST be in accordance with manufacturers recommendations.
required to operate?
Yes
No
Yes
No
Yes
No
Yes
No
7.
Qualifications and licences
Personnel 1
Personnel 2
Personnel 3
Personnel 4
Personnel 5
Name
Qualifications/Competency
Site specific induction
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Construction industry induction (e.g. white card)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Driver’s licence
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Other (e.g. high risk work licence)
8.
Emergency planning (tick or add as applicable) –
Attach a copy of your emergency plan
Emergency type
Emergency equipment available (detail equipment onsite)
Fire/Explosion
Fire extinguisher
Location of equipment
Injury
First Aid kit
First Aid Officer
Location of equipment
Contact number
Work at height
Rescue plan
Location of equipment
Other
Safe Work Method Statement (SWMS)
Page 3 of 4
9.
National Legislation, Regulation, Codes of Practice and Australian Standards
Applicable legislation and regulations
National Codes of Practices/Guidance
10. Risk Assessment Matrix
Likelihood
Consequence
Consequence
(5) Almost Certain – The event is
(5) Catastrophic – A Fatality
expected to occur
Likelihood
Negligible (1)
Minor (2)
Moderate (3)
Major (4)
Catastrophic (5)
(4) Likely – The event will probably occur
(4) Major – Long term or extensive
in most years and has occurred once in
injury or illness and/or significant
Almost certain (5)
Moderate (5)
Moderate (10)
High (15)
Extreme (20)
Extreme (25)
the last year
and long term psychological
injury sustained by one or more
workers or officers
Likely (4)
Low (4)
Moderate (8)
Moderate (12)
High (16)
Extreme (20)
(3) Possible – The event might occur
(3) Moderate – Medical attention
at some time and may have
required and/or psychological
Possible (3)
Low (3)
Moderate (6)
Moderate (9)
Moderate (12)
High (15)
occurred in the last two years
intervention/treatment required for
one or more workers or officers
Unlikely (2)
Low (2)
Low (4)
Moderate (6)
Moderate (8)
High (10)
(2) Unlikely – The event could occur at
(2) Minor – First aid required and/or
some time and may have occurred in
one off counselling for one or more
Rare (1)
Low (1)
Low (2)
Low (3)
Low (4)
Moderate (5)
the last five years
workers or officers
(1) Rare – The event may occur but only in
(1) Negligible – No medical attention
exceptional circumstances and may have
required
occurred in the last ten years
Safe Work Method Statement (SWMS)
Page 4 of 4
11. Risk assessment
Step
Relevant
Task step
Potential hazard(s)
Risk assessment
Risk control measures
List each individual step required to complete
Against each step, list the potential hazards that could
(use the risk
For each hazard, identify the control measure to eliminate or control the risk
the activity
cause injury or illness
assessment matrix
as far as reasonably practicable.
Yes No
at Section 10)
L
M
H
E
1
L
M
H
E
2
L
M
H
E
3
L
M
H
E
4
L
M
H
E
5
L
M
H
E
6
L
M
H
E
7
L
M
H
E
8
L
M
H
E
9
L
M
H
E
10
L
M
H
E
12. SWMS training induction register
Name of worker
Signature
Date
Signature
Name of worker
Date
Name of worker
Signature
Date
Name of worker
Signature
Date