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Safety Work Method Statement and Work Request
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Safety Work Method Statement and Work Request
date_time
id
Risk Assessment ID
CONTRACT JOB OWNER DETAILS
Contract Job Owner Details
Contract Job Owner Name
Please select
Alan Johnston
Billy McKinstray
Frank Green
John Calderwood
Neil Hamilton
Paul Jackson
William McWhinnie
Contract Job Owner Location
Contract Job Owner Department
Please select
Contract Job Owner Telephone Number
Job / Task Details
Will this work come under CDM 2015
No
Yes
No
SWMS Start Date Requested
SWMS Time Requested
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SWMS Plant Location
Dummy
t link to Separate table
SWMS Area or Equipment
SWMS Brief Description of Work
SWMS Has Local Access Egress been agreed
No
Yes
SWMS Is Work Start Date Agreed
No
Yes
SWMS Company Authorisation Name
SWMS Has Pre-Work Discussion Taken Place
No
Yes
SWMS Pre-Work Discussion Contractor Name
SWMS Pre-Work Discussion Company Name
SWMS Has the Job Work Location Been Inspected
No
Yes
SWMS Job Work Location Inspect Contractor Name
SWMS Job Work Location Inspect Company Name
SWMS Estimated Duration (Work Days)
SWMS Purchasing Conditions Applicable
1
2
3
4
5
6
7
8
What Type of Supervision is this Contract
Contractor Supervised
Sub-Contractor Supervised
Company Supervised
Have Site Regulations Been Employed to Complete SWMS
No
Yes
SWMS Is this the first time Contractor has been used by Company
No
Yes
SWMS Company Purchase Order Number
SWMS Any Agency Personnel
No
Yes
SWMS Lone Worker Application
No
Yes
SWMS Any Contractor Employees Under 18
No
Yes
SWMS Any Contractor Consultant Employees
No
Yes
SWMS Any Contractor Employees Over 65
No
Yes
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
No
Yes
Safety Helmet Details
Safety Footwear
No
Yes
Safety Footwear Details
Eye Protection
Yes
No
Eye protection Details
Hearing Protection
Yes
No
Hearing Protection Details
High Visibility Wear
Yes
No
High Visibility Wear Details
Personal Dangerboards
Yes
No
Personal Dangerboards Details
Respiratory Protection
Yes
No
Respiratory Protection Details
Breathing Apparatus
Yes
No
Breathing Apparatus Details
1.3 COMAH Substances
Are COMAH Substances Involved
Yes
No
Is Safety Critical Equipment Involved
Yes
No
1.4 Proximity Working
Will the work be on or near the following, please tick Yes or No.
Company Hazardous Operations
Yes
No
Bus - Bars or Open Electrical Equipment
Yes
No
Chemical Plant or By-Products
Yes
No
Conveyors
Yes
No
Excavations or Fall Openings
Yes
No
Hot Products or Material and Substances
Yes
No
OH Cranes or Crane Tracks
Yes
No
Open Water or Liquid Tanks or Channels
Yes
No
Overhead Cables
Yes
No
Rail Tracks
Yes
No
Roads or Walkways
Yes
No
Underground Areas
Yes
No
Site Traffic or Transport
Yes
No
1.5 Manual Handling
Manual Handling
Are Manual Handling Equipment or Procedures Required
Yes
No
Manual Handling Details
Lifting of large boxes
1.6 COSHH
COSHH Not Applicable
Not Applicable
Are COSHH Regulations relevant
Yes
No
Have COSHH Assessments been Supplied
Yes
No
COSHH Details
COSHH Documentation
COSHH Link
1.7 Guarding
Task necessitate working within Area Guarded Plant
Yes
No
Area Guarded Plant Details
Task required removal of fixed guarding
Yes
No
Fixed Guarding Removal Details
1.8 Fire Prevention Assessment
(a) Is acetylene to be used
Yes
No
Will the work involve bringing onto site any heat source or spark forming equipment?
Yes
No
flammable Liquids or gases
Yes
No
Working involves fire extinguishers
Yes
No
Will any fire barriers be breached
Yes
No
Breached Fire Barrier Numbers
Breached Fire Barrier Location Details
Cause False fire Alarms from fire detection equip
Yes
No
Identify any Hot Work in High Risk Areas
Type of fire extinguishers to be provided
Water
Powder
Gas
Foam
Number of Fire Extinguishers Provided
Who will supply the fire extinguishers
Contractor
Site
Will a fire watcher be provided
Yes
No
How Many Fire Watchers
Will a fire blanket be provided
Yes
No
Who will supply the fire blanket
Contractor
Site
Is the area to be water flooded
Yes
No
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
Yes
No
supervisor_national_safety_passport No Details
Is the WPL Site and Plant Inducted
Yes
No
Not Site or Plant Inducted Details
2.2 Contractor Personnel Training
Estimate Number of Personnel to be Employed
Contractors
Sub-Contractors
Agency Staff
Consultants
Self Employed
Are all Personnel in receipt of Valid Nation Safety Passport
Yes
No
Personnel No National Safety Passport Details
Are all Personnel Site and Plant inducted
Yes
No
Personnel Not Site or Plant Inducted Details
Contractor Personnel Competency Details
2.3 Sub-Contractor Personnel Training
Are all Sub-Contractors Craft/Trade Competent
Yes
No
Sub-Contractor Competency Details
Sub-Contractor Personnel Valid NSP
Yes
No
Sub-Contractor Personnel No Valid NSP Details
Sub-Contractor Personnel Site and Plant Inducted
Yes
No
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
Yes
No
More than 6 days in a week
Yes
No
PART 3 - PLANT EQUIPMENT, TOOLS AND TACKLE
3.1 Plant Equipment Tools Tackle Authorisation
Is Business Authorisation Required
No
Yes
Detail and List any Agreed Plant Equipment 1
Authorised By 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
Yes
No
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
Yes
No
Electrical Power Tools
Yes
No
Hydraulic Power Tools
Yes
No
Pneumatic Power Tools
Yes
No
Burning Gear
Yes
No
Cutting Gear
Yes
No
Heating Gear
Yes
No
Welding Gear
Yes
No
Cryogenic Freezing
Yes
No
Disc Cutters
Yes
No
Grinding Machines
Yes
No
Pressurised Jetting Gear
Yes
No
Power Saw or Cutters
Yes
No
3.4 Contractor Equipment and Tackle
Tick the following yes if to be used provide details below
Crane Cradle or Bosuns Chair
Yes
No
Gas Bottles
Jacking Equipment
Yes
No
Ladders or Steps
Yes
No
Platforms or Tressels etc
Yes
No
Scaffolding any type
Yes
No
Site Flood Lighting
Yes
No
Sky Lifts or Cradles
Yes
No
Slings or Lifting Tackle
Yes
No
GAs Equipment Fitted with FBA, NRV and Crimp fittings
Yes
No
Are Portable Lamps to be used
Yes
No
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
Yes
No
Detail Where these Legal and mandatory Records will be kept
Records Contact Name
Records Contact Phone Number
4.1 Isolation
Are Isolations required
Yes
No
Detail Electrical and Mechanical Isolations
Isolation Details
Detail who will apply isolation's
Electrical Cables to be cut or disconnected
Yes
No
4.2 Immobilisation
Are Immobilisations Required
Yes
No
Detail any Plant or Equipment to be immobilised
Immobilisation Details
Who will Apply Immobilisations
Are pressurised Systems to be broken into
Yes
No
4.3 Site Housekeeping
Will Walkways be kept clear
Yes
No
Will there be a need for storage on site
Yes
No
Will there be cabins offices or workshops onsite
Yes
No
Detail housekeeping Control Arrangements
4.4 Health and Hygiene
Are Occupational Health or Hygiene aspects Involved
Yes
No
Are Welfare Facilities to be provided
Yes
No
Provide Details of Welfare Facilities provided
4.5 Environmental Issues
Will any Rubbish or Waste burning be necessary
Yes
No
Will the work involve Waste discharge into drains
Yes
No
Will the work involve any air pollution
Yes
No
Will any forms of waste get into ground or land
Yes
No
Will there be any excessive noise pollution with this work
Yes
No
Are any wastes of any type produced taken from site
Yes
No
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
Yes
No
Upload Monitoring Record Documentation
Monitoring Record Link
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