Safe Work Method Statement (SWMS) This SWMS template is provided as a guide for contractors to use when developing

or contractors to use when developing a SWMS for Page 1 of 4

the activities undertaken by the business.
1. Organisation details
Company name ABN

Business address Contact name

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

State Postcode MITM number SWMS date Version

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
the last year and long term psychological Almost certain (5) Moderate (5) Moderate (10) High (15) Extreme (20) Extreme (25)
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
the last five years workers or officers Rare (1) Low (1) Low (2) Low (3) Low (4) Moderate (5)

(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

Name of worker Signature Date

Name of worker Signature Date

Name of worker Signature Date