SWMS - Roadside Works Electrical

Client Name
Site Name
Site Address
Job number
Date SWMS provided to client:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Work Activity:
Select all that apply
Review Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Brief description of work activity
Site Supervisor
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Site Supervisor - Signature
Plant and equipment required for this activity:
Select all that apply
Licenses required:
Select all that apply
Details of maintenance checks required for this activity:
Select all that apply
Materials used:
SDS required?
Yes / No
PPE required for this activity:

Other
High-risk Works (please cross 'X' for all applicable)
Heights higher than 2m.
Type 'X' if applicable
Work on, in or adjacent to a road, railway or other traffic corridor in use by traffic other than pedestrians.
Type 'X' if applicable
Work on or near chemical, fuel or refrigerant line.
Type 'X' if applicable
Work in or near water other liquid that involves a risk of drowning.
Type 'X' if applicable
Installing statutory signage
Type X if applicable
Work in or near a shaft or trench deeper than 1.5m or a tunnel.
Type 'X' if applicable
Work in areas with an artificial extreme of temperature.
Type 'X' if applicable
Work likely to involve disturbing asbestos.
Type 'X' if applicable
Work on or near energised electrical installations or services.
Type 'X' if applicable
Conducting a site survey from the ground.
Type 'X' if applicable
Work in an area with movement of powered mobile plant.
Type 'X' if applicable
Work on or near pressurised gas mains or piping.
Type 'X' if applicable
Work in or near a confined space.
Type 'X' if applicable
Work in an area that may have a contaminated or flammable atmosphere.
Type 'X' if applicable
Permit required (please cross 'X' for all applicable)
Working at heights
Type 'X' if applicable
Man Cage
Type 'X' if applicable
Hot Works
Type 'X' if applicable
Penetration/drilling
Type 'X' if applicable
Confined Space
Type 'X' if applicable
Crane
Type 'X' if applicable
Traffic Control
Type 'X' if applicable
Electrical Isolation
Type 'X' if applicable
EWP
Type 'X' if applicable
Excavation
Type 'X' if applicable
Personell qualifications required for this activity (relevant state certification has been undertaken for use of plant)
Specific training required for this activity: All personell to have completed site induction Must be trained in this SWMS and have all relevant certification for this task

Personnel consulted on development of SWMS:

Rows	Name	Position	Industry experience
1
2
3
4

Person responsible for updating SWMS
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pause and Make Safe required?
Initial here if you selected 'No'
Preliminary (make a plan) required?
Initial here if you selected 'No'
Setup work zones required?
Initial here if you selected 'No'
Working outdoors required?
Initial here if you selected 'No'
Works likely to involve disturbing asbestos required?
Initial here if you selected 'No'
Work on or adjacent to a road, railway or corridors used by traffic other than pedestrians required?
Initial here if you selected 'No'
Working on or near energised electrical installations or services required?
Initial here if you selected 'No'
Wiring required?
Initial here if you selected 'No'
Removing existing signage required?
Initial here if you selected 'No'
Fixing signs to walls required?
Initial here if you selected 'No'
Pack down and clean up work zone required?
Initial here if you selected 'No'

SIGNOFF We, the undersigned, confirm that the SWMS nominated above has been explained and its contents are clearly understood and accepted. We also confirm that our required qualifications to undertake this activity are current. We also clearly understand the controls in this SWMS must be applied as documented; otherwise work is to cease immediately.

Rows	Name	Qualification Required for this Activity	Date	Time	High Risk Licence number & Expiry (if required)
Person 1
Person 2
Person 3
Person 4
Person 5

Person 1 Signature
Person 2 Signature
Person 3 Signature
Person 4 Signature
Person 5 Signature
A copy of this document will be sent to pm@expresswaysigns.com.au. If you would like to send this form to other recipients, please enter their email addresses into the following fields.
1. Email for SWMS recipient (i.e. Installer)
example@example.com
2. Email for SWMS recipient (i.e. Client)
example@example.com
3. Email for SWMS recipient (i.e. Forman)
example@example.com
Should be Empty: