Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Client
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Job Number
Untitled Page
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Scaffold Handover Certificate
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Site Details (Supervisor to complete)
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Location
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Scaffold Location
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Site Address
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Date of Handover
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Personnel Details
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Supervisor Name
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Team Leader Name
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Team Member Name
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Type of Size of Scaffold
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Type of Scaffold
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Tube and Coupler
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Ring lock
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Modular/Other
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Number of Working Platforms
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Duty Category or Working Platforms
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Light
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Heavy
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Special
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Duty Category or Working Platforms
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Number of lifts above base lifts
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Scaffold Height
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Number of Bays long
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Scaffold length
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Type of Access
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Ladder
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Staircase
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Ramp
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Other
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Type of Access
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Design Drawing Reference
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Inspection Completed and Approval of Works “Compliant”
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Supervisor Name
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Signature
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Date
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Team Leader Name
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Signature
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Date
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Work Crew Representative Name
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Signature
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Date
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Scaffold Inspection Checklist
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Item No
Item Description
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Is the scaffold fit for task?
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Has the responsible persons working on the scaffold been to see the job and have they signed off the job?
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Has all of the spare scaffold and associated equipment been removed?
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Has the shift supervisor inspected the scaffold?
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Is the correct scaff tag number attached?
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Are Infills required?
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Is kick lift as low to the ground as possible?
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Is there a gate on scaffold access?
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Are all boards lashed down?
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Kick boards in place and suitable?
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Ladder handrail in place above 2m or near open edge?
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Has ladder been fixed to two standards (not a 700 ledger or Hop Up)?
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Have work hours been captured on the m/order?
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All braces been fitted to comply with standards AS/NZ 1576?
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Is area tidy - no trip hazards?
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If hung Scaffold; are the checks in place and correct?
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Is the Scaffold tied correctly (maximum 4m apart)?
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Do the screw jacks have sole boards under them to transfer the weight (not applicable if on Concrete)?
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Has all of the exclusion tape been removed?
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Has all spare equipment been stacked correctly in Yard?
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Has all working at heights equipment been accounted for?
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Has scaffold been photographed and Scaffold Scope Sheet been Finalised?
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Site
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Light
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Location
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Type
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Heavy
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Date
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Special
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Designed By
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Maintain Supervisor Sign Off
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Name
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Date
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Signature
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End User Supervisor Sign Off
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Name
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Date
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Signature
