SCAFFOLDING INSPECTION SHEET

Lembar Inspeksi Scaffolding

Date of Inspection :

Type of Inspection :

Duties of Scaffolding :

Purpose of Scaffolding :

Location :

Name of Scaffolder : 1 …………………… 2 ……………………..

3 …………………… 4 ………………………

Condition
Inspection Item Specification Remarks
No Kondisi
Item Inspeksi Spesifikasi Keterangan
Good Poor
1 Base/Dasar Ground/Tanah
Concrete/Lantai Semen
Base Plates/Landasan
Adjustment Base
Plates/Pengaturan landasan
Planking,Matting/Papan
Leveling/Kedataran
2 Standard /Tiang Pipe Diameter/Diameter Pipa
Length/Panjang
Leveling (vertical)/Lurus keatas
Couplers/Klemp
Pins, Sprockets/Sambungan Pipa
3 Ledger/Pipa mendatar Pipe Diameter/Diameter Pipa
Length/Panjang
Leveling (Horizontal)/Kedataran
Couplers/Klemp
Pins,Sprockets/Sambungan Pipa
4 Transom Pipe Diameter/Diameter Pipa
Length/Panjang
Levelling/Kedataran
Couplers/Klem
5 Putlog Pipe Diameter/Diameter Pipa
Length/Panjang
Levelling/Kedataran
Couplers/Klem
 Condition
Inspection Item Specification Remarks
No Kondisi
Item Inspeksi Spesifikasi Keterangan
Good Poor
6 Bracing Face Brace/Permukaan Bracing
 Pipe Diameter/Diameter Pipa
Length/Panjang
Couplers/Klem
7 Guard Rail (Ledger Pipe Diameter/Diameter Pipa
guard rail) Length/Panjang
Levelling/Kedataran
Couplers/Klem
Pins or Sprockets/Sambungan
Pipa
Guard Rail(Transom Pipe Diameter/Diameter Pipa
guard rail) Length/Panjang
Levelling/Kedataran
Couplers/Klem
Guard Rail Safety Net/Jaring Safety
8 Platform Planking Condition/Kondisi
Papan
Widht/Lebar
Length/Panjang
Clearance (Plank to Plank)
End to end roping
9 Toe Board Planking Condition/Kondisi
Papan
Height/Tinggi
Clearance
End to end roping
10 Ladder (Aluminium) Condition/Kondisi
Length/Panjang
Putlogs/Roping Ties
Angle/Sudut
Ladder (Pipe) Nominal Diameter
Condition/Kondisi
Height/Tinggi
Putlogs/Roping Ties
Angle/Sudut
Couplers/Klem
11 Gin Wheel/Roda Condition/Kondisi
S.W.L
Safety Couplers/Klem
Safety Catch
Hoist Rope
12 Tie - In (Permanent Condition and Strenght/Kondisi
Struct) dan kekuatan
Tie – In (Building) Condition and streght/Kondisi dan
kekuatan
Bridles
Couplers/Klem

Condition
Inspection Item Specification Kondisi Remarks
No
Item Inspeksi Spesifikasi Good Poor Keterangan

13 Chain standards
 Access (Ladder Access Chain Condition
or Manhole) Landing Platform
Access (Material Access) Chain Standards
Chain Condition
14 General Surface Levelling/Kedataran
Safely/Keselamatan
15 Others

SAFETY RECOMMENDATION
Inspected by: Signature: