Title Page
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Select date
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N.C. Not Checked N.A. Not Applicable
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1<br>Has a assessment been undertaken to determine whether there is a risk of persons falling 2 metres or more?
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2<br>Are SWMS developed for activities where workers are exposed to a fall greater than 2 metres and are relevant persons trained in them ?
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3<br>Is a system in place to ensure that equipment used for accessing elevated works are regularly checked and maintained in a safe condition.
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4<br>Has an assessment been undertaken to determine risks to people below the immediate work area and have appropriate control measures been implemented.
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5<br>Is a rescue procedure in place for those working at height and are relevant persons trained in the procedure and is the procedure rehearsed ?
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6<br>Are persons required to use fall arrest system(s) instructed in their fitting and safe use, and are they competent in the use, care, storage and inspection of the fall arrest system.
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7<br>Wherever possible, do anchorage points bear a loading of 15kN (1,529kg) for a single person anchorage?
SCAFFOLD
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8<br>Is scaffold where a person or object could fall 4 metres or more, erected by a person holding the basic level scaffolding certificate of competency, or higher?
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9<br>Is scaffold where a person or object cannot fall more than 4 metres, erected to manufacturer's Specifications?
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10<br>Is scaffold where a person or object cannot fall more than 4 metres, erected to manufacturer’s specifications?Colm Groogan
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11<br>Is there a fenced, secure work platform installed where persons are at risk of falling over 2 metres or, if this is not practicable, is there a fall arrest/restraint system installed? (Handrail: 900mm to 1100mm, Middle rail : 400mm to 600mm )
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12<br>Does the scaffold have a safe means of access/egress?
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13<br>Is incomplete scaffold signposted as "NOT FOR USE"
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14<br>Are handover certificates issued for scaffolds where a person or object could fall 4 metres or more?
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15<br>Is there a local identifying number issued and a register maintained (for maintenance recording purposes) for completed scaffold that 4 metres or more?
16 Is there a system for regular, documented inspections of scaffold where persons can fall greater than 4m:
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<br> . Before its first use, and<br>
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as soon as practicable, and before its next use, after an occurrence that might reasonably be expected to affect the stability or adequacy of the scaffold or its supporting structure, such as a severe storm or earthquake, and
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before its use following repairs,
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at intervals not exceeding 30 days?
BATTERS
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17<br>Has a risk assessment been completed for batters with an incline/decline exceeding 15 Degs (1:3.7 ) where workers are within 2 metres of the edge of the batter that could fall greater than 2 metres?
LADDERS
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18<br>Are Ladders all rated for industrial use?
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19<br>Is the ladder marked with the relevant information?<br>( eg industrial/ commercial use, load rating, name of manufacture, working length of the ladder, "DO NOT USE WHERE ELECTRICAL HAZARDS EXIST" sign "USE IN THE FULLY OPENED POSITION ONLY", a warning against standing on those rungs which represent an unsafe working position( step ladder - no higher than the second top tread, single or extension ladder - no higher than the 3rd top rung)
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20<br>Are portable ladders used as a short -term solution for access/egress where no other access/egress option are practicable?
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21<br>Do portable ladders have a local identtifying number legibly painted on both sides?
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22<br>Does the user of a non-self-supporting ladder need to access above the second rung?
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23<br>Is a local register of ladders maintained on site?
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24<br>Is the top of the ladder secured against any movement and the base of the ladder secured against sliding away from the supporting structure?
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25<br>Are documented inspections of ladders conducted every 6 months?
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26<br>Are extension ladders positioned at a pitch angle of no less than 1:4 and no greater than 1:6?
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27<br>Has fall protection been provided where a permanent ladder is used for access and a free fall in excess of 2 metres is possible?
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28<br>Do ladders extend 1 metre above the landing height (900 mm for ladders used on scaffolds)?
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29<br>Are users of ladders following the “three points of contact” rule whenever possible?
Compliance and Follow-up Actions
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Is the activity Compliant
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Surveillance Officer
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NCPN or Memo Number
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Follow-up Action
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Product Non Conformance
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System non conformance
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Contractor generated NCR
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Contractor generated CAR
Matters Arising
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NCPN no
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Contractors NCR Number
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CAR Number
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Closed out
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Representative's Name