NHCP - Scaffold Release - Initial Inspection For Site Use

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

This form is to be signed & completed jointly by the Scaffold Erector and CMJV Authorized Competent Person.

• Scaffold Builder / Erector:

• Competent Person:

• Scaffold Being Released: (Brief Description)

• Scaffold Location:

• CMJV Scaffold Competent Person:

• Scaffold Inspection Date:

  Date

• CMJV Superintendent Assigned to Work Scope Related to Scaffold Use:

Inspection Results / Comments:

• Scaffold Builder Competent Person present at time of initial inspection?

  Yes

  No

  N/A

• Competent Person Certifications Verified?

  Yes

  No

  N/A

• Scaffold built to the submitted engineering specifications and drawings.

  Yes

  No

  N/A

• Scaffold meets OSHA 1926 Subpart L and EM 385 requirements?

  Yes

  No

  N/A

• All safety requirements for the area around the scaffold that could impact use addressed and controlled?

  Yes

  No

  N/A

• Scaffold meets the safe working load requirements for the planned and intended work to be preformed on the scaffold?

  Yes

  No

  N/A

• Photos (Optional):

  Media

Comments and Restrictions / Limitations:

• Comments and Restrictions / Limitations:

Signatures:

• CMJV Competent Person:

  Sign

• CMJV Superintendent:

  Sign

• Scaffold Erector CP:

  Sign

• Scaffold Erector Authorized Representative:

  Sign

If any item is deemed out of compliance, release by CMJV is declined until Scaffold Erector corrects deficiencies.