Safe Work Method Statement
Complete this form to outline work activities, associated risks, and safety controls for your project.
Project or Job Name
*
Location of Work
*
Date of Work
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Work Activity
*
List all personnel involved in this activity
*
Identify Hazards Associated with the Task
*
Slips, trips, and falls
Manual handling
Working at heights
Electrical hazards
Chemical exposure
Other
Risk Assessment (Select the risk level before controls are applied)
*
Low
Medium
High
Control Measures to Be Implemented
*
Personal Protective Equipment (PPE) Required
Hard hat
High visibility clothing
Safety boots
Safety glasses
Gloves
Other
Person Responsible for Implementing Controls
*
Additional Comments or Site-Specific Requirements
Acknowledgment: I have read and understood this Safe Work Method Statement and agree to comply with the control measures and safety requirements.
*
Submit Statement
Submit Statement
Should be Empty: