SCAFFOLD INSPECTION FORM

TYPE OF SCAFFOLD: □ FRAME □ TUBE & CLAMP □ SYSTEM LOCATION & DATE: ____________________________
ERECTOR/COMPETENT
MAXIMUM INTENDED LOAD: _____________________________ PERSON NAME:

CONDITION OBSERVATIONS /
NO. ITEMS TO BE CHECKED
OK COMMENTS
1 Scaffold components are in good condition?
2 Scaffold connections are secured?

3 Scaffold is level and plumb; resting on base plates (supported scaffols) and a
firm foundation?
4 Crossbracing is installed betweel scaffold legs?
5 Scaffold is contructed to support maximum intended load?
6 Wheel locks are operable on mobile scaffold (If any)?
Plank installation is correct and secure. Cleats are seated or planks are
7 properly extended (6 to 12 in. [15 to 30 cm]) beyond sill for lengths up to 10
ft (3.05 m)

8 Overlap is a minimum of 12 in. (30 cm) and extends 6 to

12 in. (15 to 30 cm) past the sill for the continuous run of planking.

Work platform fall protection:

* Fully planked within 9-1/2 in. (22.8 cm) of side rails
* Top rail (36 to 45 in. [ 91 to 1114 cm])
9 * Midrail (approximately centered)
* Toeboards
* Access
* Gate (or equal) where rails are missing
10 Loose hinges
11 Loose, broken or missing extension locks
12 Defective locks that do not seat properly when the ladder is extended
13 Deterioration of rope from exposure to weather or other destructive agents
Structure is stabilized against tipping if necessary. Secure at the nearest
horizontal bar as follows:
14 * Initially, secure at a height 4 times the minimum base dimension.
* Periodically, secure every 26 ft (7.9 m) unless the narrow dimension is 3 ft
(0.9 m) or less – then secure at 20-ft (6.1-m) increments.
* Secure at the nearest vertical bar every 30 ft (9.1 m) of length.

15 Minimum clearance from overhead power lines maintained as per applicable

legislation (750-150,000 Volts 10Ft)
16 Rolling scaffold wheel brakes locked and outriggers extended to maintain
maximum height of three times the smallest base dimension
17 Warning devices/signs provided if erected over walkways or roadways
(flashing lights, reflective tape streamers or area is roped off).
18 Scaffold status tag is completed and attached near the
access point.

Re-Approval Sunday Monday Tuesday Wednesday Thursday Saturday

Signature

Note:
1. This checklist shall be done every week by user prior to use of SCAFFOLD and be submitted to HSE Department on weekly basis.
2. Re-Approval / Inspection shall be done and signed on daily basis by user prior to use.
3. Any defects to the Scaffold must be reported and the Scaffold removed from use and marked with a label / tag to ensure further use is prohibited. All repair work to Scaffold may only be
carried out by a competent person.

REMARKS:

INSPECTOR NAME : ____________________________

DATE OF INSPECTION : __________________

INSPECTOR SIGNATURE

Form HS-INS-03
Revision 0 dated 09/01/217