Information
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Document No.
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Job Site/Number
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Conducted on
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Weather Conditions
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Prepared by
Section 1
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Has the scaffold been erected under the supervision of the competent person?
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Are base plates being used?
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Are mudsills properly installed?
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Is scaffold plumb and level?
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Have scaffold components been inspected for damage?
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Are scaffold components from different manufacturers being used?
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Has the competent person deemed this acceptable?
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Are all cross braces in place?
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Is safe access/egress provided?
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Are any sources of electricity within 10 feet of the scaffold?
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Are scaffold planks made of scaffold grade lumber and in good condition?
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Are planks covered with paint or any opaque finishes?
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Are all working areas fully planked?
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Are scaffold platforms at least 18 inches wide?
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Do scaffold planks extend over the centerline of the support at least 6 inches and no more than 12 inches unless cleated or restrained?
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When scaffold planks are abutted to form a longer platform, does the overlap occur over supports?
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Is the overlap at least 12 inches unless nailed together or otherwise restrained?
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Where platforms change direction, are planks properly supported?
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Is the scaffold able to support its maximum intended load?
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Has the scaffold reached a height requiring it to be tied into the structure?
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Is the distance between the front edge of scaffold platform and the face of work 14 inches or less (18 inches for plastering and lathing)?
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Is fall protection being provided at 6 feet for employees working on the scaffold?
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Where guardrails are used, are they installed along all open sides and ends of platforms?
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Is the toprail installed between 38 and 45 inches and capable of supporting 200 lbs?
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Is the midrail installed halfway between the toprail and the platform and capable of supporting 150 lbs?
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If crossbraces are used to replace a midrail or toprail, are the end points at each upright 48 inches apart or less?
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Is fall protection feasible for employees erecting or dismantling scaffodl?
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If personal fall arrest systems are being used, will the anchorage support 5000 lbs?
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Are employees working below protected from falling objects by use of toeboards, netting, etc...?
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If toeboards are used, are they at least 3.5 inches high?
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Do toeboards have a 1/4 inch or less clearance between the bottom of the toeboard and the walking or working surface?
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Please describe in detail any items above not checked as acceptable and the corrective action taken:
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Competent Person Signature