Safe Work Method Statement Declaration

SAFE WORK METHOD STATEMENT DECLARATION

Safe Work Method Statement (SWMS): ...... (Document Reference)

I, the undersigned, in my capacity as * Owner of / * Senior Manager (strike out the item which is not applicable) of the below named company certify that:

(a)I am an Owner/ Senior Manager who:

(i)has the most senior responsibility for the safety of employees, sub contractors and the public; and

(ii)has sufficient practical OHS experience to declare the Safe Work Method Statement as being adequate; and

(iii)have a working knowledge of the relevant OHS legislation related to these works, in particular “high risk construction work” (defined OHS Regulations 2007), if relevant; and

(iv) will represent the company in any WorkSafe interventions, prosecutions or incident investigations.

(b)The Company currently:

(i)is incorporated and I have included the Certificate of Incorporation (ACN) number;

(ii)has a Victorian Workcover insurance policy or proof of self insurance which covers all personnel working on VicRoads worksites or office premises; and

(iii)runs a business that offers its services to the public generally (not just VicRoads); and

(iv)has a written procedure that details how VicRoads and WorkSafe will be notified of any incident requiring notification as specified in the Occupational Health and Safety Act 2004 . The Procedure includes the manner in which the incident site will be secured pending WorkSafe instructions.

Company Name: …………………………………………… (ACN No)…………………

Victorian WorkCover Insurance/Self Insurance: ......

Expiry Date:......

(c)Public Liability insurance has been effected for an amount of at least $10 million for any one claim, unlimited in any one year for bodily injury or property damage claims and is issued with industry agreed broad form wording on a claims occurring basis;

(d)I have familiarized myself with all works to be undertaken;

(e)I have reviewed and assessed the Safe Work Method Statement and it:

(i)addresses all the works to be carried out;

(ii)satisfies all relevant legislative and regulatory requirements;

(iii)in particular, where relevant complies with OHS Regulations 2007 Chapter 5, Part 5.1 - Construction;

(iv)addresses all the requirements of the VicRoads Safe Work Method Statement (SWMS) Checklist; and

(f)In signing this declaration, I endorse the Safe Work Method Statement and supporting Documents and/or systems as adequate and fit for purpose. I will ensure that if the works are not carried out in accordance with the SWMS the work will immediately cease and not recommence until the controls as specified in the SWMS are implemented. I will review and endorse any changes made to the SWMS to ensure they fulfil the OHS obligations for the contracted works.

Signed......

Name (please print)…………………………………………………………………….

Company Position (please print) ………………………………………………………..

On behalf of(please print)...... (Company)

Date......

Version 2 21 August 2008Page 1 of 1