Title Page
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Site conducted
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Scaffold Incident Report
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Conducted on
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Prepared by
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Location
Scaffold Report
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UNSAFE SCAFFOLD REPORT
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Client:
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Date:
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Site:
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Scaffold Tag No:
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Scaffold Location;
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Block-
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Level(s)
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Elevation-
The above scaffold has failed the weekly inspection/spot check for the following reasons: -
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Scaffold boards damaged
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Scaffold ties removed
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Scaffold fittings removed
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Toe boards removed
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Scaffold structure damaged
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Platforms overloaded
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Foundation undermined
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Handrails removed
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Platforms not cleared of debris
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Ladders removed
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Materials stacked above toe board
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Scaffold tubes cut
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Ladders damaged
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Scaffold boards removed
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Others, please state below
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Please Highlight the Severity of Issue
- Catastrophic -Operating conditions are such that human error, environment, design deficiencies, element, subsystem or component failure, or procedural deficiencies may commonly cause death or major system loss, thereby requiring immediate cessation of the unsafe activity or operation.
- Critical-Operating conditions are such that human error, environment, design deficiencies, element, subsystem or component failure, or procedural deficiencies may commonly cause severe injury or illness or major system damage thereby requiring immediate corrective action.
- Marginal- Operating conditions may commonly cause minor injury or illness or minor systems damage such that human error, environment, design deficiencies, subsystem or component failure, or procedural deficiencies can be counteracted or controlled without severe injury, illness, or major system damage.
- Negligible-Operating conditions are such that personnel error, environment, design deficiencies, subsystem or component failure, or procedural deficiencies will result in no, or less than minor, illness, injury, or system damage
- Other
- N/A
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Please Highlight the Probability of Issues
- Frequent - Likely to occur often in the life of an item
- Probable- Will occur several times in the life of an item
- Occasional-Likely to occur sometime in the life of an item.
- Remote- Unlikely but possible to occur in the life of an item
- Improbable- So unlikely, it can be assumed an occurrence may not be experienced.
- N/A
- Other
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Description of Unsafe Use of scaffold Observed – what has happened, who is responsible and what are the significant hazards as a result?
- Unauthorised Scaffold Modification by Third Party
- N/A
- Other
Action taken
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If ‘NO’ then please give the reason
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Works stopped?
- Yes
- No
- N/A
- Unautorised Scaffold Modification by Third Party
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Area made safe?
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Photos taken?
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Embassy site management informed?
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Client’s supervisor informed?
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Client site management informed?
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Name:
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Signature:
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Embassy Site Services - Site Manager’s Recommendations:
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Name:
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Signature:
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Client Acknowledgement of Unsafe Scaffold Report:
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Name:
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Signature:
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Distribution : One signed copy retained by the Client and Depot/Site, with a copy emailed to Embassy Director
