Form 4.0 – Method Statement
Form 4.0 – Method Statement Revision:	
Part A – Contractor Details	
Company Name	Contact Name
	
Address	Phone
	
	Email
	
Part B – Project Details	
Project Title
	Site Address	
Description of Task / Activity	
PSCS Address

	Start Date:
	End Date:	
	Start Time:	End Time:	
PART C – Personnel Involved	
Name	Role / Trade	

		

		

		

Site Supervisor

	Phone:	Email:	
Safety Officer / Advisor

	Phone:	Email:	
Part D – Equipment Required	
Key Plant & Tools (Attach Certification if Applicable)

	
Key Materials

	
Other Essential Equipment
	
Part E – Safety	
Specific Residual Identified Hazards (Or refer to the task specific risk assessments)	
Specific Staff Training (e.g. CSCS)	
Sequence of Operations (Include sketches if required)	
Details of coordination / interaction required with project supervisors, contractors and others	
Temporary Works needed to facilitate the permanent works (if none, state none)

	
Fall Protection Measures (Where work at height cannot be eliminated – consider both personnel and materials)

	
Safe Working Loads (SWLs) – Detail any limits on the loading applicable to temporary plant/equipment or fixed elements of the structure where the work is taking place 

Detail Permits to Work (If applicable)

Utility / Power Shut Down Required?	
Required Personal Protective Equipment (PPE)	

Safety Boots	
Hard Hats	
Safety Gloves	
Hearing Protection	
Eye Protection	
Respiratory Protection	
Hi-Viz

Yes         No
	Yes         No
	Yes         No
	Yes         No
	Yes         No
	Yes         No
	Yes         No
	
Other PPE Required (Please State)

Services to be supplied by others

Other Information and Comments

Part F – Hazardous Substances
Attach chemical risk assessments if required	
List Hazardous Substances & Identify Risks Below

Explosives	
flammable Liquids	Oxidising Liquids	Compressd Gases	Corrosive	Acute Toxicity	Skin Irritation	Aspiration Hazard	Hazardous to the Aquatic Environment	
Yes     No	Yes     No	Yes     No	Yes     No	Yes     No	Yes     No	Yes     No	Yes     No	Yes     No	
Storage Arrangements

Part G – Emergency Procedures & Welfare Requirements	
First-Aid Facilities

Name of First Aider

	Phone	
First-Aid Box Location

Location of Nearest Hospital

Welfare Requirements

Declaration
All work will be undertaken by qualified, competent persons with experience of the type of work described above and, in all cases, in full accordance with safety procedures specified in the company’s health and safety policy	
Prepared By	
Name	Signature	Date

Reviewed By	
Name	Signature	Date

Part H – Items Attached	
Sketches	Certification of Plant, Etc.	Programme of Work	Risk Assessments	Training Records	
Yes               No
	Yes               No
	Yes               No
	Yes               No
	Yes               No
	
Information Supplied Previously

Part J – Method Statement Briefing Record
Briefing Delivered by	
Name

	Signature	Date	
We (the undersigned) have read and understood the attached method statement and will comply with the specified requirements and control measures. If the work activity changes or deviates from that originally envisaged, we will seek further advice and request an amended method statement.	
Name	Signature	Date