Site Survey Form

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Select date

  Date

• Client/Customer

• Contact Name: Phone Numbers: Email Address:

• Site Address

Scaffold Requirements

• Description of scaffold required:

• Hire Period if Known:

• Sketch of Area Scaffold Required

  Drawing

• Picture of area or elevations

  Media

• Base/Ground Conditions:

• Is a paving license required?

  Yes

  No

  N/A

• Physical Ties to building or Rakers required?

  Physical Ties

  Rakers/Butress

• Does this scaffold require a design?

  Yes

  No

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

  Yes

  No

  N/A

• Vehicular access good or bad?

  Good

  Bad

• Carry Materials?

  Yes

  No

  N/A

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

Risk Assesment for carrying out works.

• Slips/Trips/Falls

• Falling/Flying Objects or Debris

• Manual Handling

• Heat/Fire

• Moving Vehicles/Site Plant

• General Public

• Dust/Fumes/Noise

• Overhead Powerlines (Sheathed or Unsheathed)

• Poor Lighting

• Other (please Identify)

Control Measures for Hazards Identified:

• Risk Control and Method:

• Signee:

  Sign