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Scaffold Checklist

Project Title (enter Project Title / desc of work for non - project work) Project #:
or Description: PTS ID#:
Project Stage:
Plant Name: Oracle Plant #: Complexity:
Owner: Sponsor: Date:
Vale Project Manager: DM#: Rev#:
Contractor / Consultant / Work Group:
Contract #: W/O #(s): PO #(s):
Type of Scaffold Erection / Dismantling:
Frame System Scaffold Green Tagged Engineered
Tube & Clamp Wood Frame Yellow Tagged

Describe Location of Scaffold: Yellow Tag Restrictions:


Installation Date:
Last Certification Date:
Planned Removal Date:
Identified Compliant Notes
Qualifications of Scaffold Erectors (Y/N) (Y/N)
1 Revew training records for Site Supervisor
2 Revew Trade Qualification ticket
Identified Compliant Notes
Engineered Scaffolding (Y/N) (Y/N)
1 Confirm size & height of scaffold is as per Drawing
2 Engineering Documents - Stamped Drawing & Approval letter
3 Verify scaffold erection to drawing provided
4 Cantilever support system being used
5 Suspended Platforms drawings are Engineered & Stamped
6 Review Scaffold Tent specifications
7 Review Balcony specifications
8 Must be less then 1 ft gap when tying scaffolding into existing
support
9 Ensure scaffold bridges are longer than 25 ft.
10 Review Rescue Plan & equipment available
Identified Compliant Notes
Scaffold Details Review (Y/N) (Y/N)
1 Review access points
2 Identify tie off points / travel restraint
3 Ensure size & quality of wood for wood scaffolds is adequate
4 Ensure anchor points / outriggers / secured to structure
5 Review condition of scaffold components
6 Ensure applicable weight capacity affixed to the scaffold
7 Check handrail, mid rail, toe board & fully planked and cleated
8 Check ladder location & cage enclosure
9 Ensure grounding to structural steel for welding
10 Daily Inspection check / date of inspection & signature
11 Review covers for holes
12 Confirm rope off area below scaffolding
13 Review procedures for working in unprotected areas
14 Confirm Construction PHR on site
15 Review general housekeeping

NAV-TP-0283 v0(draft) Page 1 of 2


Scaffold Checklist
Identified Compliant
Modification Review (Y/N) (Y/N) Notes
1 Modifications approved by Engineer of Record?
2 Hazard Identification and Assessment Screens Reviewed?
3 Fall Prevention / Protection Selection Considerations Reviewed?
4 Fall Prevention / Protection Options Reviewed?
5 Falling Objects Control reviewed?
Reviews & Approvals
Modification Approved Name (Print) Date Signature
Review Yes No N/A

NAV-TP-0283 v0(draft) Page 2 of 2

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