Corporate Construction Group (CCG) - Scaffolds

• Project Name

• Prepared by

• Title

• Project Manager

• Conducted on

  Date
• Add location
  Address

A. PERSONNEL SAFE WORK PRACTICES

• 1. Competent person has completed work shift inspection and has authorized scaffold access

  Yes

  No

  N/A

• 2. Personnel aware of and following access requirements established by competent person

  Yes

  No

  N/A

• 3. Scaffold free from damage and in stable condition

  Yes

  No

  N/A

• 4. Safe means of access provided to scaffold platform

  Yes

  No

  N/A

• 5. Personnel remaining within guardrail system when provided

  Yes

  No

  N/A

• 6. Personnel using personal fall arrest systems (PFAS) when required

  Yes

  No

  N/A

• 7. Personnel working from suspension scaffolds or boatswains’ chairs using PFAS

  Yes

  No

  N/A

• 8. CH2M HILL personnel have completed CH2M fall protection training when PFAS use required

  Yes

  No

  N/A

• 9. Personnel not standing on objects to stand on on top of scaffold platforms

  Yes

  No

  N/A

• 10. Personnel not using ladders on top of scaffold platforms

  Yes

  No

  N/A

• 11. Personnel not working on scaffolds covered with snow or ice

  Yes

  No

  N/A

• 12. Personnel not work on scaffolds during storms/high winds unless adequate protection provided

  Yes

  No

  N/A

B. GENERAL

• 13. Scaffolds inspected by competent person before each work shift

  Yes

  No

  N/A

• 14. Damaged or weakened scaffold components immediately repaired or replaced

  Yes

  No

  N/A

• 15. Scaffolds not loaded in excess of their maximum intended load

  Yes

  No

  N/A

• 16. Debris is not accumulating on scaffolds platforms

  Yes

  No

  N/A

C. ASSEMBLY/DISASSEMBLY OF SCAFFOLDS

• 17. Scaffolds designed by qualified person

  Yes

  No

  N/A

• 18. Scaffolds assembled/disassembled by experienced and trained personnel

  Yes

  No

  N/A

• 19. Scaffolds assembled/disassembled under supervision and direction of competent person

  Yes

  No

  N/A

• 20. Adequate planking provided, as determined by competent person

  Yes

  No

  N/A

• 21. Adequate safe means of access provided, as determined by competent person

  Yes

  No

  N/A

• 22. Adequate fall protection provided, as determined by competent person

  Yes

  No

  N/A

D. EARTHMOVING EQUIPMENT PLACEMENT

• 23. Scaffolds capable of supporting own weight and 4 times maximum intended load

  Yes

  No

  N/A

• 24. Compatible scaffold components used

  Yes

  No

  N/A

• 25. Scaffolds uprights bear on stable foundations

  Yes

  No

  N/A

• 26. Scaffolds adequately braced to prevent racking/collapse

  Yes

  No

  N/A

• 27. Scaffolds plumb, level, and squared

  Yes

  No

  N/A

• 28. Scaffolds with height to width ratios greater than 4:1 secured from tipping

  Yes

  No

  N/A

• 29. Work platforms fully planked or decked

  Yes

  No

  N/A

• 30. Platform planking extends over supports appropriate amount or restrained

  Yes

  No

  N/A

• 31. Safe means of access is provided to platforms

  Yes

  No

  N/A

• 32. Supported scaffolds > 10 feet provided with guardrails or PFAS

  Yes

  No

  N/A

• 33. When required, adequate guardrail system installed on all platform open sides and ends

  Yes

  No

  N/A

• 34. When required, adequate PFAS provided (may also use fall protection checklist HS31)

  Yes

  No

  N/A

• 35. Falling object protection provided to personnel working on scaffolds/under scaffolds

  Yes

  No

  N/A

• 36. Safe clearance maintained from overhead power lines

  Yes

  No

  N/A

E. MOBILE SCAFFOLDS

• 37. Casters/wheels locked while scaffold used in the stationary position

  Yes

  No

  N/A

• 38. Personnel not riding mobile scaffolds unless safe to move

  Yes

  No

  N/A

F. EARTHMOVING EQUIPMENT MAINTENANCE

• 39. Suspension scaffolds and boatswains’ chairs > 10 feet provided with personal fall arrest system

  Yes

  No

  N/A

• 40. Supporting devices/counterweights secured to supporting structure <br>

  Yes

  No

  N/A

• 41. Supporting devices inspected by competent person prior to scaffold use

  Yes

  No

  N/A

• 42. Ropes and connecting hardware capable of supporting 6 times the maximum intended load

  Yes

  No

  N/A

• 43. Suspension ropes inspected by competent person before each work shift

  Yes

  No

  N/A

• 44. Damaged or repaired wire rope not used as suspension rope

  Yes

  No

  N/A

• 45. Suspension ropes joined together only by eye splice thimbles connected by shackles

  Yes

  No

  N/A

• 46. Wire rope clips inspected/retightened after initial loading and before each work shift

  Yes

  No

  N/A

• 47. Scaffold ropes protected from welding, heat, and corrosives

  Yes

  No

  N/A

• 48. Scaffolds tied or otherwise secured from swaying

  Yes

  No

  N/A

G. ADJUSTABLE SUSPENSION SCAFFOLDS

• 49. Adjustable suspension scaffolds > 10 feet provided with guardrails and PFAS

  Yes

  No

  N/A

• 50. Supporting structures capable of resisting tipping moment

  Yes

  No

  N/A

• 51. Hoist ropes restrained from passing through the hoist

  Yes

  No

  N/A

• 52. Hoists have braking device/locking pawl that engages during scaffold uncontrolled movements

  Yes

  No

  N/A

• 53. Manually operated hoists require positive crank force to lower

  Yes

  No

  N/A

• 54. Scaffold hoist stall load less than 3 times its rated load

  Yes

  No

  N/A

• 55. Gasoline-powered hoists not used

  Yes

  No

  N/A

Corrective Action Taken

• Corrective actions & dates corrected

• Signature

  Sign