Method Statement Checklist Form
Complete this form to review and confirm key controls for the method statement. Ensure all checklist items are addressed for task and safety compliance.
Project / Site Name
*
Method Statement Reference
*
Reviewer Name
*
First Name
Last Name
Date of Review
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are all required control measures in place?
*
Yes
No
Not Applicable
Checklist of Key Controls (tick all that are confirmed in place)
*
Permit to Work issued
PPE available and worn
Emergency procedures briefed
Tools and equipment checked
Hazards identified and controlled
Other (please specify)
Are there any outstanding actions required?
*
No outstanding actions
Yes – see below
Comments / Outstanding Actions
I confirm I have reviewed this method statement and checklist.
*
Acknowledged
Submit Checklist
Should be Empty: