Select date


Contact Name: Phone Numbers: Email Address:

Site Address

Scaffold Requirements

Description of scaffold required:

Hire Period if Known:

Sketch of Area Scaffold Required
Picture of area or elevations

Base/Ground Conditions:

Is a paving license required?

Physical Ties to building or Rakers required?

Does this scaffold require a design?

Is the scaffold to be sheeted? If so please state whether monarflex or debris netting.

Vehicular access good or bad?

Carry Materials?

Are there any special,requirements? Ie. Confined space or rescue personnel in attendance. if so, please state requirement.

Risk Assesment for carrying out works.


Falling/Flying Objects or Debris

Manual Handling


Moving Vehicles/Site Plant

General Public


Overhead Powerlines (Sheathed or Unsheathed)

Poor Lighting

Other (please Identify)

Control Measures for Hazards Identified:

Risk Control and Method:

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.