Method Statement Checklist
Project Name
*
Contractor
Method Statement author
*
Description of works
Start date:
-
Month
-
Day
Year
Date
Finish date:
-
Month
-
Day
Year
Date
Scope of works clearly described
*
Yes
No
N/A
Notes
Safe material storage identified
*
Yes
No
N/A
Comments
Safe access and egress identified
*
Yes
No
N/A
Notes
Key contact identified
*
Yes
No
N/A
Notes
Roles and responsibilities defined
*
Yes
No
N/A
Notes
Supervision & monitoring of works identified
*
Yes
No
N/A
Notes
Operative competencies defined
*
Yes
No
N/A
Notes
Suitable plant and equipment identified
*
Yes
No
N/A
Notes
Supporting risk assessments
*
Yes
No
N/A
Notes
Control and monitoring in place
*
Yes
No
N/A
Notes
Method statements
*
Yes
No
N/A
Notes
Other services affected
*
Yes
No
N/A
Notes
Permits to work available/in use
*
Yes
No
N/A
Notes
Isolation/identification of services
*
Yes
No
N/A
Notes
Are the works being carried out in sterile/restricted areas?
*
Yes (If yes, has required PPE been identified?)
No
N/A
Other
Notes
Traffic management in place
*
Yes
No
N/A
Notes
Waste/environmental controls
*
Yes
No
N/A
Notes
MS communicated to employees
*
Yes
No
N/A
Notes
Personal protective equipment
*
Yes
No
N/A
Notes
Emergency procedures identified
*
Yes
No
N/A
Notes
Has scaffolding safety been recognised, including suchthings as locked gates, and ladder removal/storage?
*
Yes
No
N/A
Notes
Procedures in place for preventing aspergillus/cross contamination?
*
Yes
No
N/A
Notes
Welfare arrangements identified
*
Yes
No
N/A
Notes
Deference to staff / visitors
*
Yes
No
N/A
Notes
Access equipment / conditions
*
Yes
No
N/A
Notes
No lone working
*
Yes
No
N/A
Notes
Bed movements
*
Yes
No
N/A
Notes
Reinstatement of ceiling grid
*
Yes
No
N/A
Notes
Cleaning regime
*
Yes
No
N/A
Notes
Do the comments require action before the works can proceed?
*
Yes
No
N/A
Notes
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