DOCUMENT TITLE:
SCAFFOLD INSPECTION FORM
Date of Inspection: Inspected by (Competent Person): ALLAN ORSABIA
Scaffold Exact Location: HCL ACID ROOM WWTP Site Safety In-Charge: LORENA CAPILI
AREA
Special Instruction: Please complete this inspection by filling in the checklist. Correct any deviation(s) and return this list to the Site
Safety In-Charge with noted correction(s).
Inspection Item Yes No Action/Comment
A completed and approved Elevated Work Permit and scaffold status
tag is attached near the access point.
Ladder, stairway, or special-design framing is installed for access.
Scaffold unit is plumb and level, and resting on stable footing and a firm
foundation (including base plates/ mud sills).
Diagonal cross bracing is in place to support legs.
Guying, tying, or bracing is installed to maintain scaffold unit stability
where height-to-base size exceeds a 4:1 ratio.
Visual inspection is completed for the presence of loose, damaged, or
missing components (such as locking pins, planking, access, framing, or
bracing).
Working level platform(s) is fully planked between guardrails and
secured to prevent movement.
Platform is free of debris and slipping/ tripping hazards.
Platform guardrails are firmly in place on all open sides/ ends, where
required.
Falling object protection is provided by installed toe boards, screening at
the working platform level(s), are barricades or canopies.
Fall protection standards are discussed to all workers.
Other safety hazards are controlled (such as pinch points, hot surfaces,
or electrical).
Other reminders while working on scaffolds:
• Use scaffolds only for their intended purpose.
• Work from tagged scaffolds only. Comply with special conditions or the additional controls noted on the access tag. Do not modify
or remove a scaffold system, component, or status tag. Notify Safety Officer immediately if a scaffold is damaged, weakened, or
otherwise deficient.
• Ensure the scaffold is always inspected before using.
• Do not use unstable objects or makeshift devices to increase the working height of the scaffolds. Use portable ladders to increase
the working height only after a COMPETENT PERSON has determined that the stability of the structure has not been
compromised and adequate fall protection is in place.
• Do not straddle, stand on, or work outside the guardrail.
• Use mobile scaffolds only on firm, level surfaces. Lock the casters or wheels before using mobile scaffolds.
• Do not “ride” on scaffold while it is being moved.
• Remove or secure any tools or materials before moving or relocating a scaffold.
• Use designated access means to descend or ascend a scaffold (stairs, attached ladder, or specially designed end frames). Do not
climb cross bracing or side rails for access.
• Keep only the tools and materials necessary to perform the tasks on the platform. Control slipping and tripping hazards by
removing or securing tools or materials.
• Use fall protection systems (guardrail systems or personal fall arrest systems) when working six (6) feet or more above a lower
level.
• Do not position yourself or use tools or equipment where there is a possibility of contacting an energized overhead line. Contact the
Maintenance Department or responsible electrician for additional requirements if any portion of your body, or the tools, or the
materials will come within 20 feet of the energized line.
