JMW Scaffold Inspection

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General

• Has scaffold been inspected by Competent Person Today?

  Yes

  No

  N/A

• is scaffold at least 10' away from energized power lines?

  Yes

  No

  N/A

• Daily JSA forms for each available for review?

  Yes

  No

  N/A

Construction

• Mudsill, base plate, and Screwjack in place?

  Yes

  No

  N/A

• Guardrails, Midrails and Toeboards installed?

  Yes

  No

  N/A

• Are working levels fully decked from to back?

  Yes

  No

  N/A

• Is there less than 1 inch gap between boards?

  Yes

  No

  N/A

• Do boards overlap at least 6 to 12 inches?

  Yes

  No

  N/A

• Are tiebacks installed perpendicular to the face of the building?

  Yes

  No

  N/A

• Are tiebacks secured to a structurally sound anchorage?

  Yes

  No

  N/A

• Do support devices rest on surfaces capable of supporting 4 x the weight?

  Yes

  No

  N/A

• Are access platforms at least 18 inches wide?

  Yes

  No

  N/A

• Do scaffold components match?

  Yes

  No

  N/A

• Add photograph of scaffold here:

  Media

• Add diagram of scaffold here:

  Drawing

Access / Fall Protection

• Is ladder access provided for employees on all working levels?

  Yes

  No

  N/A

• Are guardrails installed at 42 inches?

  Yes

  No

  N/A

• Are mid rails or X-brace installed at 21 inches?

  Yes

  No

  N/A

• Are open ends at each working level blocked off or have pass gate?

  Yes

  No

  N/A

• Are toe boards or screens installed?

  Yes

  No

  N/A

• Add photograph of scaffold here:

  Media

Baker / Perry

• Rolling scaffold wheels locked when employee using?

  Yes

  No

  N/A

• Have handrails been installed if platform over 6 feet?

  Yes

  No

  N/A

• If double stacked have outriggers been attached?

  Yes

  No

  N/A

• Add photograph of scaffold here:

  Media

Review

• Superintendent signature

  Sign

• Safety Director signature

  Sign