Safety Work Method Statement and Work Request

Risk Assessment ID

CONTRACT JOB OWNER DETAILS

Contract Job Owner Details

Contract Job Owner Location

Contract Job Owner Telephone Number

Job / Task Details

Will this work come under CDM 2015

SWMS Start Date Requested

SWMS Time Requested

::

SWMS Area or Equipment

SWMS Brief Description of Work

SWMS Has Local Access Egress been agreed

SWMS Is Work Start Date Agreed

SWMS Has Pre-Work Discussion Taken Place

SWMS Pre-Work Discussion Contractor Name

SWMS Pre-Work Discussion Company Name

SWMS Has the Job Work Location Been Inspected

SWMS Job Work Location Inspect Contractor Name

SWMS Job Work Location Inspect Company Name

SWMS Estimated Duration (Work Days)

SWMS Purchasing Conditions Applicable

Have Site Regulations Been Employed to Complete SWMS

SWMS Is this the first time Contractor has been used by Company

SWMS Company Purchase Order Number

SWMS Any Agency Personnel

SWMS Lone Worker Application

SWMS Any Contractor Employees Under 18

SWMS Any Contractor Consultant Employees

SWMS Any Contractor Employees Over 65

PART 1 - SAFETY ASPECTS

1.1 Hazards & Risks

Refer to the Hazard Identification Number

Refer to the Risk Assessment Number

1.2 Protective Equipment and Clothing

Safety Helmet

Safety Helmet Details

Safety Footwear

Safety Footwear Details

Eye Protection

Eye protection Details

Hearing Protection

Hearing Protection Details

High Visibility Wear

High Visibility Wear Details

Personal Dangerboards

Personal Dangerboards Details

Respiratory Protection

Respiratory Protection Details

Breathing Apparatus

Breathing Apparatus Details

1.3 COMAH Substances

Are COMAH Substances Involved

Is Safety Critical Equipment Involved

1.4 Proximity Working

Will the work be on or near the following, please tick Yes or No.

Company Hazardous Operations

Bus - Bars or Open Electrical Equipment

Chemical Plant or By-Products

Conveyors

Excavations or Fall Openings

Hot Products or Material and Substances

OH Cranes or Crane Tracks

Open Water or Liquid Tanks or Channels

Overhead Cables

Rail Tracks

Roads or Walkways

Underground Areas

Site Traffic or Transport

1.5 Manual Handling

Manual Handling

Are Manual Handling Equipment or Procedures Required

Manual Handling Details

1.6 COSHH

COSHH Not Applicable

Are COSHH Regulations relevant

Yes

Have COSHH Assessments been Supplied

COSHH Details

COSHH Documentation

COSHH Link

1.7 Guarding

Task necessitate working within Area Guarded Plant

Area Guarded Plant Details

Task required removal of fixed guarding

Fixed Guarding Removal Details

1.8 Fire Prevention Assessment

(a) Is acetylene to be used

Will the work involve bringing onto site any heat source or spark forming equipment?

flammable Liquids or gases

Working involves fire extinguishers

Will any fire barriers be breached

Breached Fire Barrier Numbers

0

Breached Fire Barrier Location Details

Cause False fire Alarms from fire detection equip

Identify any Hot Work in High Risk Areas

Type of fire extinguishers to be provided

Number of Fire Extinguishers Provided

0

Will a fire watcher be provided

How Many Fire Watchers

0

Will a fire blanket be provided

Is the area to be water flooded

PART 2 - CONTRACTOR PERSONNEL AND SAFETY TRAINING

2.1 Supervision

Working Party Leader Names 1

Working Party Leader Safety Passport No 1

Working Party Leader Names 2

Working Party Leader Safety Passport No 2

Working Party Leader Names 3

Working Party Leader Safety Passport No 3

Working Party Leader Names 4

Working Party Leader Safety Passport No 4

IS the WPL in Receipt of Supervisor National Safety Passport

supervisor_national_safety_passport No Details

Is the WPL Site and Plant Inducted

Not Site or Plant Inducted Details

2.2 Contractor Personnel Training

Estimate Number of Personnel to be Employed

Contractors

0

Sub-Contractors

0

Agency Staff

0

Consultants

0

Self Employed

0

Are all Personnel in receipt of Valid Nation Safety Passport

Personnel No National Safety Passport Details

Are all Personnel Site and Plant inducted

Personnel Not Site or Plant Inducted Details

Contractor Personnel Competency Details

2.3 Sub-Contractor Personnel Training

Are all Sub-Contractors Craft/Trade Competent

Sub-Contractor Competency Details

Sub-Contractor Personnel Valid NSP

Sub-Contractor Personnel No Valid NSP Details

Sub-Contractor Personnel Site and Plant Inducted

Sub-Contractor Personnel not Site and Plant Inducted Details

2.4 Hours of Work

Will any of the contractors or other employees work:-

More than 16 hr shifts

More than 6 days in a week

PART 3 - PLANT EQUIPMENT, TOOLS AND TACKLE

3.1 Plant Equipment Tools Tackle Authorisation

Is Business Authorisation Required

Detail and List any Agreed Plant Equipment 1

Detail and List any Agreed Plant Equipment 2

Authorised By 2

3.2 Contractor Plant & Transport

Are there any Transport or Mobile Plant Requirements

Give Details of any Transport or Mobile Plant

Details of any Transport or Mobile Plant

3.3 Portable Tools

Tick the following yes if to be used

Cartridge Power Tools

Electrical Power Tools

Hydraulic Power Tools

Pneumatic Power Tools

Burning Gear

Cutting Gear

Heating Gear

Welding Gear

Cryogenic Freezing

Disc Cutters

Grinding Machines

Pressurised Jetting Gear

Power Saw or Cutters

3.4 Contractor Equipment and Tackle

Tick the following yes if to be used provide details below

Crane Cradle or Bosuns Chair

Gas Bottles

Jacking Equipment

Ladders or Steps

Platforms or Tressels etc

Scaffolding any type

Site Flood Lighting

Sky Lifts or Cradles

Slings or Lifting Tackle

GAs Equipment Fitted with FBA, NRV and Crimp fittings

Are Portable Lamps to be used

3.5 Contractor Passenger Vehicles

List any Company Vehicles - Reg - Fleet Number

3.6 Records

Will all Legal Mandatory Test Certs and Schedules be avalable

Detail Where these Legal and mandatory Records will be kept

Records Contact Name

Records Contact Phone Number

4.1 Isolation

Are Isolations required

Detail Electrical and Mechanical Isolations

Isolation Details

Detail who will apply isolation's

Electrical Cables to be cut or disconnected

4.2 Immobilisation

Are Immobilisations Required

Detail any Plant or Equipment to be immobilised

Immobilisation Details

Who will Apply Immobilisations

Are pressurised Systems to be broken into

4.3 Site Housekeeping

Will Walkways be kept clear

Will there be a need for storage on site

Will there be cabins offices or workshops onsite

Detail housekeeping Control Arrangements

4.4 Health and Hygiene

Are Occupational Health or Hygiene aspects Involved

Are Welfare Facilities to be provided

Provide Details of Welfare Facilities provided

4.5 Environmental Issues

Will any Rubbish or Waste burning be necessary

Will the work involve Waste discharge into drains

Will the work involve any air pollution

Will any forms of waste get into ground or land

Will there be any excessive noise pollution with this work

Are any wastes of any type produced taken from site

4.6 Monitoring and Final Inspection

Who will be responsible for H&S Safety Monitoring

Monitoring Frequency (Details)

Monitoring Records Location

Who will carry out Final Work check and Safety inspection

Will a record of (a) and (e) be Provided to contract job owner

Upload Monitoring Record Documentation

Monitoring Record Link