Appendix D Example Scaffold Request Form Scaffold Request Form Department: SRF Number: 0000 Name of Position: Requestor: Location Details: Task Details (provide information on the intended use of the scaffolding and loading): Duty (if known) Typical Tasks Tick One worker per m2 - inspection, light Class 1 - Very Light Duty 0.75 kN/m2 cleaning and access etc… no materials or equipment. Two workers per m2 – Light maintenance, Class 2 Light Duty 1.5 kN/m2 – painting, cleaning or access. Two workers + 50Kg of materials per m2 – Class 3 – General Purpose 2 kN/m2 General maintenance or access Two workers + 100Kg of materials per m2 – Class 4 Heavy Duty 3 kN/m2 – Heavier maintenance work or access. Special Loading requirements must be – Classes 5-6 - Special Purpose designed and calculated – e.g. loading tower, lifting frame etc. Date Date Duration (if Requested: Required: Safety Management Systems: Workplace Surveyed with Yes Risk Assessment (HEMP) Yes Scaffolding Contractor? No Completed? No Yes Yes Permit to Work Required? Isolations Required? No No Emergency Arrangements Yes established? No Additional Information:
Appendix D Example Scaffold Request Form Scaffold Request Form Department: SRF Number: 0000 Name of Requestor: Position: Location Details: Task Details (provide information on the intended use of the scaffolding and loading): Duty (if known) Typical Tasks Tick Class 1 - Very Light Duty 0.75 kN/m2 One worker per m2 - inspection, light cleaning and access etc… no materials or equipment. Class 2 – Light Duty 1.5 kN/m2 Two workers per m2 – Light maintenance, painting, cleaning or access. Class 3 – General Purpose 2 kN/m2 Two workers + 50Kg of materials per m2 – General maintenance or access Class 4 – Heavy Duty 3 kN/m2 Two workers + 100Kg of materials per m2 – Heavier maintenance work or access. Classes 5-6 - Special Purpose Special Loading requirements – must be designed and calculated – e.g. loading tower, lifting frame etc. Date Requested: Date Required: Duration (if Safety Management Systems: Workplace Surveyed with Scaffolding Contractor? Yes No Risk Assessment (HEMP) Completed? Yes No Permit to Work Required? Yes No Isolations Required? Yes No Emergency Arrangements established? Yes No Additional Information: