Scaffold Location / Description _______________________________________________________________

Note:
SECTION A.
Yes No
1a
1b
1c
2a
2b
2c
2d
2e
2f
2g
2h
2i
2j
3a
3b -
3c -
3d -
3e -
3f -
3g
3h
3i
3j
3k
3l
3m
3n
4a
SECTION B.
5a
5b
5c
5d
5e
5f
5g
6a
6b
6c Other:
Erector Organization Proponent Loss Prevention
Signature
Print Name
Print Organization
Date
Telephone Number
Other information
Attachments or ties to buildings or structures / guy wires to concrete blocks
If stairs are used, adequate handrails are provided and detailed
Scaffold Specifications
Scaffold Drawings
Maximum number of working levels noted
Total number of planked/platformed levels noted
Ladders or other access to all working levels
SCAFFOLDS OVER 12.2 meters (40 feet) - LPD Review Required
Drawn to scale on at least "A3" size paper and scale noted on drawings
Scope of Work
Manufacturer's specifications and technical data for materials, planks, fittings, etc., included
Tubing size (diameter, wall thickness) and material specification (including yield stress) noted
All potential obstructions and interferences (piping, cable trays, platforms, etc.) shown and cleared
Elevation views show complete layout of all vertical members (posts, braces, etc.)
All areas to remain free of scaffold obstructions shown (roads, corridors, etc.)
Complete design calculations provided verifying safety factor of 4 for scaffold and all components
Design loads, including uniformly distributed and concentrated loads and locations
SCAFFOLD PLAN COMPLETENESS CHECKLIST (40ft and above)
Drawings adequately show complete construction information and details for the scaffold:
Base support details, including base plates and sills
Guardrail systems' locations, dimensions, and toprail, midrail and toeboard sizes
Posts, bearers, runners, horizontal (plan) and vertical bracing, etc.
Is this scaffold plan complete (Y/N)?
Coupler Safe Working Loads (SWL)
The needed information, as shown above, has been verified as being contained within this scaffold plan package by:
Structural Calculations
Calculations legible
Calculations checked and approved by a qualified civil/structural engineer
Support Information/Technical Data
Calculations verifying foundation and/or existing supporting structure capacity
Calculations prepared as per SAES-A-204 (including plots if computer program printouts submitted)
If required, wind load analysis for all critical wind directions as per SAES-A-112
Load Tables for posts, bearers, planks, etc.
Length and width of scaffold at base
Height of scaffold
SPECIAL SCAFFOLDS - including scaffolds OVER 38 m (125 ft) - CSD Review Also Required
Names and contact phone numbers for the proponent organization and scaffold erector organization
Note or signature on drawings to show they have been checked for accuracy
Plan views show complete layout of all horizontal members (bearers, runners, horiz. bracing, etc.)
Scaffold fully and properly dimensioned
Platform units type, size, and material specified
For scaffolds over 12.2 meters (40 feet), complete section "A".
For "Special Scaffolds," including scaffolds over 38 meters (125 feet), complete both sections "A" and "B".
Maximum intended load (personnel, equipment, tools, and materials) per working level noted
Exact Location where the scaffold will be erected
Brief description of work to be performed from the scaffold
Duration of work
Type of scaffold (tube & coupler, fabricated tubular frame, system, etc.)
Classified as Light-duty, Medium-duty, or Special-duty scaffold
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