Scaffolds

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Personnel

Erection & Dismantling

• Only trained, competent persons involved

  Yes

  No

  N/A

• *Daily Assessment: Need for & feasibility of fall protection. ( During the complete time frame of scaffold erection and/or dismantling, this daily assessment must be made and this checklist signed and dated)

  Yes

  No

  N/A

• Hard hat always worn<br>

  Yes

  No

  N/A

• Other PPE as appropriate; steel toed boots, gloves, eye protection

  Yes

  No

  N/A

• Supported scaffold poles, legs, posts, frames, and uprights resting on base plates and mud sills or other adequate firm foundation

  Yes

  No

  N/A

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  Media

• Frames, legs, braces: plumb, level and secure

  Yes

  No

  N/A

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  Media

• Locking Pins: in place and secure

  Yes

  No

  N/A

• Created planks used or planks extend at least 6" and not more then 12" over support.

  Yes

  No

  N/A

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  Media

• Planks over 10' do not extend more then 18" over support

  Yes

  No

  N/A

• No more then 1" space between platform units as well as uprights

  Yes

  No

  N/A

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  Media

• Supported scaffold with height to base width greater than 4:1 restrained by guying, tying, bracing, or equivalent means.

  Yes

  No

  N/A

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  Media

• Safe distance from power lines: <br><br>Insulated Lines:<br>1. Less then 300 Volts: 3 feet<br>2. 300 volts to 50kv: 10 feet<br>3. More then 50kv: 10 feet plus .4" for each 1 kv over 50 kv<br><br>Uninsulated lines:<br>1. Less then 50kv: 10 feet<br>2. More then 50kv: 10 feet plus .4" for each 1kv over 50kv

  Yes

  No

  N/A

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  Media

• Above 10'; installation of guard rails, mid rails, toe boards

  Yes

  No

  N/A

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  Media

• Above 2'; access if provided by stairs, ladder, ramp,...

  Yes

  No

  N/A

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  Media

• Components inspected: defective items removed from site

  Yes

  No

  N/A

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  Media

• If appropriate, warning signs, barricade tape in place. This would be need if work is commencing on 2 or more scaffolds high.

  Yes

  No

  N/A

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  Media

• Temporary wiring clear of employee & vehicular traffic

  Yes

  No

  N/A

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  Media

• Guard rail systems [ on all *open sides and ends] installed before scaffold released for employee use<br>* An open side is greater then 14" from the face of the work except:<br>1. For plastering and lathing, it is greater then 18" from the face of the work<br>2. For outrigger scaffolding, it is 3" from face of work

  Yes

  No

  N/A

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  Media

Scaffold Use

• Daily Inspection by competent persons. Is this recorded?

  Yes

  No

  N/A

• Only trained employees on scaffolding

  Yes

  No

  N/A

• Hard hats always worn

  Yes

  No

  N/A

• Employees not standing on guardrail a or mid rails or cross rails

  Yes

  No

  N/A

• Employees not standing on boxes or step ladders on scaffold to gain height

  Yes

  No

  N/A

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  Media

• Potential falling objects, to large to be contained by toe-boards, mess, etc.. Will be placed away from edge.

  Yes

  No

  N/A

• Scaffolds will not be loaded above there capacity. Under no circumstances will platforms deflect more then 1/60 the span when loaded

  Yes

  No

  N/A

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  Media

• Scaffold planks are in good condition.

  Yes

  No

  N/A

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  Media

Other

• NAVFAC jobs have correct red or green scaffold tag indication

  Yes

  No

  N/A

• Add signature

  Sign