Work Method Statement

Site Name: Location of Work: Maintenance Activity: Submitted by:

Approved by Senior Manager

Will any of the following tasks be performed under this Works Request (Separated Permit or statement to be attached);

Hot Works ✘ Yes Energized Electrical Work Yes Confined Spaces Work ✘ Yes Work At Height ✘ Yes Others High Risk Work: Yes, Pls Specify

Section 2: Work Method Statement With Risk Analysis

Item Method/Step Risk Identified Risk Control Areas Affected

Section 3: Facility Service Isolation/Interruption Summary

Isolation Finish
Item Date Isolation Start Time System Disabled or Interrupted Discription
Time
1
*Please note that the isolation will not be performed unless the person stated contacts the Facilities Manager to inform them they are ready to start work, the work
can not start until the isolation has been confirmed.

Section 4: Materials & Parts

Item Materials / Parts Brand Model Purpose Quantity

Section 5: Tools & Instruments

Item Tools/Instruments Brand Model Purpose Quantity

Section 6: Workforce Register

Item Company Name Name of Person Involved Activities Certificate Contact Phone Induction?
NOTES ON COMPLETION OF THIS DOCUMENT (if required, additional method statement forms should be attached):
Method Statement shall Cleary state pre-execution, execution and post-execution steps with associated risk analysis and proposed risk control measures, if this analysis can not be
fully addressed by this form due of work task complexity, a additional statement or risk analysis with drawing, diagram and others supporting shall be attached for review.
(I) METHOD - The job or task is to be broken down into individual steps to provide a clear statement of how the job is to be done, including any tools and equipment and any hot
works/riser or void access, etc. Generic method statements will not be accepted. Method statements MUST apply to the job in hand.
(ii) RISKS IDENTIFIED - Detail any potential risks to property, personnel, business operations.
(iii) RISK CONTROLS - Detail all measures to be taken to eliminate or mitigate risks identified.
(iv) AREAS AFFECTED - Areas possibly affected by the identified risks.
All person who will execute or involve this maintenance activities must hold compulsory certificate for code requested work, or qualified training certificate from authorized agency or
their company for not code mandatory requirement.
All person who are going to execute or involve this maintenance activities must be inducted by representative with regard to Health, Safety and Environment in the business and
workplace area prior to execution of any activity, without been properly inducted, anyone can't allowed to proceed any work!
r Manager

Yes, Pls Specify

Areas Affected

d Discription
are ready to start work, the work

Quantity

Quantity

Induction?
measures, if this analysis can not be
ll be attached for review.
tools and equipment and any hot

ertificate from authorized agency or

nvironment in the business and