CMSRA to be attached to permit and displayed at jobsite.

COMBINED METHOD STATEMENT and RISK ASSESSMENT

Task Planning
Permit/Work Order No: Name of Company: Dept: Date:

ABC CIVIL 21-JUNE-2021

General Description:
Loading, Unloading and Shifting of Jersey Barrier

Emergency Action Plan (Risk Management)

Area / Unit / Building Name (please KAUST TIER-lll DATA CENTER PHASE 1 WORKS
specify):

Emergency contact number/s: Nearest Evacuation Route:

Dial 0128080911 ASSEMBLY AREA

Nearest Assembly Area: Safety shower / eye washer located  Yes  No
Main Gate GDH, Temporary Office Area
and Lay down
Communication
Stop work conditions (reminders)
Adjacent work hazards Chemical spills or releases Excessive noise Fires and explosions

Fire/Toxic Gas Evacuation

Change in conditions Extreme weather Unusual odours
alarm
Supervisor and worker comments / change in conditions:

Approvals/Review Print Name KAUST Mobile Signature Date

ID# Number
Project Receiver. MOHAMED
183061
AHTASHAM 0580231385
Construction
Manager/ Site MAHMOOD KHAIRY 163534 0593107747
Engineer.

RFI’s completed
/issued/attached.

Contractor
Safety Rep. MUHAMMAD NIAZ 169562 0582794547

E&PM Project
FAZAL B. HASAN 145786 0568942208
Engineer.
E&PM Safety
Specialist. JAIME S MACARAEG 156253 0535205345

To be filled by service provider / contractor

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 DEPARTMENT NAME POSITION BADGE/ID NO. DATE SIGN

Supervisor Details:
Yrs. Of
Name Company BADGE /ID No. Qualifications Experienc SIGN
e in Role

Operatives Details
Yrs. of Experience in
Name Company Badge/D No. Trade/skills
Role

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I confirm that I have read and understand the attached RAMS and will assist to implement the
Controls required to the Hazards.
NAME POSITION SIGNATURE

Ashraf Elbaz Civil Foreman

Ahmed Marei Civil Foreman

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To be filled by service provider / contractor

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 RISK ASSESSMENT MATRIX
Damage Injury

4 4
Total Fatality 4 8 12 16
Failure

3 3
Major Major 3 6 9 12
OUTCOME

2 2
Minor Minor 2 4 6 8

1 1
Nil No Injury 1 2 3 4

1 2 3 4
Unlikely Possible Probable Definite

PROBABILITY

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 RISK = PROBABILITY x OUTCOME

Probability means the likelihood of something going wrong.

Outcome means the result when something goes wrong.
The simple Matrix below allows calculation of risk even for non-skilled operatives

METHOD STATEMENT

A Method Statement is an agreement between the workforces, Service Provider and the Person
or Organization requesting the work and that the work being undertaken is being managed and
any risk is mitigated to an acceptable level.
The method of work must be clearly communicated and understood by all parties involved.
Operatives undertaking the works the works supervisor and line managers must sign the
document as agreement with the method of works.

It must be noted that more than one method statement may be required for any sequence of
works.
Method statements and risk assessments go hand in hand, as the method of work is dictated
by the risks identified, and the risk is identified by the proposed method of work.

When conducting risk assessments in the first instance all built in safety experience must be
ignored. This will allow true identity of the risks associated with what work is proposed. Then
methods of work can be developed to reduce risk to an acceptable level.

PLANT AND EQUIPMENT

TEST
SERIAL DATE OF LAST
ITEM NAME CERTIFICATE REMARKS
NUMBER MAINTENANCE
ATTACHED

HAND TOOLS

02 Mobile Crane

Bobcat

Forklift

Ladders

Low-bed Truck

Safety Barricades

Signage

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Page 7 of 7