Scaffolding Risk Assessment And Method Statement Form
Use this form to assess scaffolding work, record site hazards, and document the safe method statement before work begins.
Project and Site Details
Project / Site Name
*
Site Address or Location
*
Client / Contractor Name
*
Date of Assessment
*
-
Month
-
Day
Year
Date
Planned Start Date
Brief Description of Work from Scaffold
*
Scaffold Configuration
Scaffold type
*
Independent
Putlog
Tower
Cantilever
Suspended
Mobile
Birdcage
Other
Maximum working height (m)
*
Number of lifts/levels
*
Approximate length / coverage area
Intended load class / use
*
Light duty
Medium duty
Heavy duty
Special duty
Access only
Other
Scaffold status
*
New
Altered
Inspected
Dismantled
Site Conditions and Hazard Assessment
Hazards Identified
*
Overhead power lines
Uneven ground
Traffic / moving plant
Excavations
Public access
Nearby structures
Poor weather
Restricted access
Falling objects
Slips / trips
Manual handling
Other
Overall Site Risk Level
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Additional Hazards Not Listed
Control Measures
*
Access, Egress, and Fall Protection
Access Method
*
Ladder
Stair tower
Internal access
Mobile access
Other
Edge Protection Arrangements
*
Guardrails
Toe boards
Brick guards
Fans/netting
Other
Tie-In and Stability Measures
*
Platform Protection and Fall Controls
*
Are the access, egress, and fall protection arrangements in place and adequate?
*
Yes
No
Partially
Not applicable
Competence, PPE, and Equipment Checks
Number of workers involved
*
Scaffolders competency/training confirmed?
*
Yes
No
Not verified
PPE required
*
Hard hat
High-visibility clothing
Safety boots
Gloves
Harness (where applicable)
Eye protection
Other
Tools and equipment checked?
*
Yes
No
Not yet checked
Special equipment needed
Method Statement, Inspection, and Emergency Arrangements
Step-by-step method statement for erection, use, alteration, and dismantling
*
Inspection frequency and responsible person
*
Permit or approval required (if applicable)
Emergency rescue or incident response arrangements
*
Final risk rating / overall assessment outcome
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Submit
Should be Empty: