Scaffolding Handover Certificate

SCAFFOLDING HANDOVER CERTIFICATE
Mine Health and Safety Act No. 29 of 1996 - General Machinery Regulations 8.8.3(h) access scaffolding is erected, used, maintained and
dismantled safely and in accordance with SANS Standard 10085-1:2004 "The design, erection, use and inspection of access scaffolding".
Scaffolding Serial No: Location of scaffold:
Work Order no:
Erection Date: Requested by:
SCAFFOLDING REQUIREMENTS AND SITE CONDITIONS

Description of work to be done from scaffolding:
Length Width Height Number of platforms

Scaffolding X X X
Size X X X
X X X
Requester to indicate the required scaffold load rating required for the scaffold structure in table below
Heavy loading-320kg/m2 Medium loading- 240kg/m2
Light loading- 160kg/m2 Very light loading- 80kg/m2

Please tick the appropriate blocks in table below to assess site specific conditions or hazards where scaffolding will be erected .
Will scaffolding obstruct machine travel ways Will scaffolding be erected in close proximity of
e.g. (TMM, Tripper cars, mobile Machines, Yes No LIVE power lines, open busbars or crane Yes No
Overhead Cranes etc.)? conductors? (See notes below on earthing)
Will there be any lifting of scaffolding Will scaffolding be erected in close proximity of
components be required? (Refer to Lifting Safe Yes No hot surfaces e.g. (Hot pipes Inside Power Plants Yes No
Work Procedure). or Smelter Areas etc.)?
Will scaffolding be erected over or in close Will scaffolding be erected in a wet and slippery
Yes No Yes No
proximity of conveyors or moving tripper cars? environment?
Will scaffolding be erected as a hanging
Will scaffolding be erected on grating? Yes No Yes No
scaffold?
Clients Request with regards to toe boards and guardrails:
ELECTRICAL SAFETY
The scaffolding erector will assess the risk with regards to electrical hazards where the scaffold is erected and inform the responsible
electrical 2.9.2 Supervisor of the area who will ensure that all electrical sources are isolated. In cases where portable electrical equipment
are to be used on or in close vicinity of scaffolding, the requestor must inform the responsible electrical 2.9.2 Supervisor who must ensure
that the scaffold is earthed in accordance with standard.
Scaffold requirements and site conditions communicated by Requester Signature Date
Scaffold requirements and site conditions acknowledged by Scaffold Erector Signature Date
DECLARATION BY SCAFFOLD INSPECTOR

Toe boards installed all-round platforms and
Foundation conditions suitable for load? Yes No Yes No
secured?
Packing installed under sole plates to stabilise or Guardrails installed all-round platforms and
Yes No Yes No
level the scaffold footing? secured?
Wheels are locked on mobile scaffold? Yes No Access to scaffold is safe and convenient? Yes No
Ties correctly installed? Yes No Ladders are secured to scaffolding? Yes No
Scaffold structure is rigid? No deflection observed. Yes No All working platforms have a trapdoor installed? Yes No
Bracing correctly installed in all directions? Yes No Do ladders extend 1 meter past platforms? Yes No
Independent Scaffolding tied to existing structure Mobile scaffold does not exceed the maximum
Yes No Yes No
every4 meters (max)? height of 6 meters?
Scaffold safe usage sign and Handover Certificate
Steel board platform completed and secured? Yes No Yes No
posted on structure?
Describe any deviations in the scaffold construction:
Scaffold structure complies to SANS 10085-1:2004 and is declared SAFE for USE.
Any alterations made to the scaffold structure not approved by the Scaffolding Erector will render the scaffold structure UNSAFE for USE.
Scaffold HANDED-OVER for use by the Scaffold Erector Signature Date
Scaffold ACCEPTED for use by the Requester Signature Date
See reverse side of Handover Certificate for the Scaffold Inspection Register.
Revision:00 Revised: 9999/12/01 Next Revision: 9999/12/01 Doc.No.

SCAFFOLD INSPECTION REGISTER
Inspection of the scaffolding must be carried out by a scaffolding inspector at the following intervals:
a) After erection of scaffolding and at least once per week thereafter.
b) After every request to alter or modify the structure during use.
c) Every time after inclement weather.
d) When the planned dismantling date is exceeded and a new date is agreed between the requester and Scaffold Erector
Date Time Scaffold Inspector Change in conditions or alterations made
Revision:00 Revised: 9999/12/01 Next Revision: 9999/12/01 Doc.No.

Scaffolding Handover Certificate

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SCAFFOLDING HANDOVER CERTIFICATE

Work Order no:

Erection Date: Requested by:

SCAFFOLDING REQUIREMENTS AND SITE CONDITIONS

Length Width Height Number of platforms

Light loading- 160kg/m2 Very light loading- 80kg/m2

DECLARATION BY SCAFFOLD INSPECTOR

Scaffold ACCEPTED for use by the Requester Signature Date

Revision:00 Revised: 9999/12/01 Next Revision: 9999/12/01 Doc.No.

a) After erection of scaffolding and at least once per week thereafter.

b) After every request to alter or modify the structure during use.

c) Every time after inclement weather.

Date Time Scaffold Inspector Change in conditions or alterations made

Revision:00 Revised: 9999/12/01 Next Revision: 9999/12/01 Doc.No.

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