Document

No.
Safe Work Method Date of
Company Logo Issue
08-12-2020
Statement Rev. No. 00
Page No. 1 of 4
Contractor to prepare method statement for the project/ activity assigned to them in the
following template & should print it either on their letterheads or on blank sheets with their
sign and seal.

Method Statement for:

No:

Date:

Section 1 – General
a) Client Name and Address: b) Contractor Name, Address, contact
<Site Address> details:

c) Description of project/assigned work:

d) Work Location:

e) Project Manager /Site Engineer /Supervisor Name: Phone No:

f) Safety Officer /Supervisor Name: Phone No:

g) Legal Permits details, numbers and validity:

 Document
No.
Safe Work Method Date of
Company Logo Issue
08-12-2020
Statement Rev. No. 00
Page No. 2 of 4
Section 2 –Details of Work

a) Sequence of Work Operations (flowcharts/additional sheets detailing all steps)

b) Hazard Identification and Risk Assessment to be attached. HIRA No-

c) P.P.E. To be used (attached MTC/TC etc.):

d) Signs, Notices, Tags to be Posted:

e) Areas to be Barricaded /Sealed Off (write in detail):

f) Access and Egress to work area (entry and exit paths):

g) Details of any other department(s) people affected due to the activity:

h) Details of any Residue that would result as part of the activity?

i) List of resources, services and specialist equipment to be used:

 Document
No.
Safe Work Method Date of
Company Logo Issue
08-12-2020
Statement Rev. No. 00
Page No. 3 of 4

j) Details of LOTO, power tools and other electrically powered equipment to be used,
with their power rating:

k) Details HAZARDOUS SUBSTANCES or DANGEROUS GOODS that would be used at

site during the activity:

HAZARDOUS SUBSTANCES or DANGEROUS GOODS USED IN THE WORKS and anticipated

volumes
(Attach MSDS if applicable):
Purpose Location
Product Controls
Date on (i.e. & Volume MSDS MSDS Attached
Name/ (& PPE to be
Site Description Applicatio Used on Date (Y/N)
worn)
n on site) Site

N.B. - All workers must be trained in the safe use of all chemicals and provided with the PPE required when using and
storing these chemicals. Disposal is to be as per the waste disposal methods in the MSDS. Spillage and leaks are to be
cleaned up as per the spill/leak procedures identified in the MSDS.

d) Waste Disposal

Sr
Waste Description Disposal Method Approval
No.

e) Emergency Response provisions (Write Details):

 Document
No.
Safe Work Method Date of
Company Logo Issue
08-12-2020
Statement Rev. No. 00
Page No. 4 of 4

f) Training Details of Supervisors, workers etc. involved need to be attached

Section 3 – TO BE FILLED BY CONTRACTOR

Method Statement prepared by -
Name: _________________________ Signature: _____________________ Date: __________

Checked and released by –

Name: _________________________ Signature: _____________________ Date: __________

Section 4 – TO BE FILLED BY CBRE

Method Statement reviewed by -
Name: _________________________________ Designation: __________________________

Department: ____________________Signature: _____________________ Date: __________

Checked and released by –

Name: _________________________ Signature: _____________________ Date: __________