22Q2996 Attachments.pdf

ATTACHMENT J-0200000-01

DEFINITIONS AND ACRONYMS

Definition Description Assessment A general term referring to either a survey or inspection of a facility to determine condition.

Asset A general term used to refer to an item, such as a component, system, building or facility, which is managed by an automated data management program.

Business Management System (BMS)

A web-based tool that provides a systematic method for the management of business processes, common practices, and process quality improvements that produce and support the most efficient and effective delivery of NAVFAC’s products and services.

Competent Person A person who has the professional experience and training necessary to identify existing and predictable hazards at a work or service environment, and who has the authority to take prompt and corrective action to eliminate or remove dangers from the environment.

Component Inventory Management Unit

(CIMU)

An organization of like-kind real property into manageable maintenance units. CIMU is a building component, group of components or component assemblies, serving a specific purpose in a facility that can be expected to follow a common and predictable lifecycle behavior. This class of non-equipment will include items such as exterior walls, exterior windows, interior finish, and roofs. This class of equipment will include items such as fan coil units, air handling units, lighting, and water closets. CIMUs can include one or more items of installed equipment typically subject to routine scheduled maintenance.

Confined Work Space A space that is large enough and so configured that a person may bodily enter a space (such as in tanks, vessels, silos, storage bins, hoppers, vaults, pits, and like spaces where there is limited means of entry) and is hindered or restricted from escaping during an emergency.

Contracting Officer

(KO)

That individual with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings. The term includes certain authorized representatives of the Contracting Officer acting within the limits of their authority as delegated by the Contracting Officer.

Contractor That entity or its representative responsible for the delivery of the services or materials specified in this contract, as designated by contract award. The term Contractor as used herein refers to both the prime Contractor and any subcontractors. The prime Contractor shall insure that subcontractors comply with the provision of this contract.

Contractor Representative

That individual appointed by the Contractor, either orally or in writing, who has been assigned responsibility for executing the requirements of this contract.

Direct Material Costs The actual vendor invoice charges for materials used for performance of work under this contract. Direct material costs shall include transportation charges when such charges are included on the invoice by the vendor, as well as any discounts allowed for prompt payment and discounts or rebates for core value or salvage value that accrue to the Contractor. When questions arise concerning the cost of materials, material costs will be based on the lowest of quotes provided by the Contractor from at least three different commercial vendors for the direct material cost. The Government retains the right to obtain additional quotes in questionable situations. The lowest price will be used.

Electronic Operation And Maintenance And Support Information (eOMSI)

A set of consultant-prepared data and document files that contain detailed, as-built technical information that describes the efficient, economical and safe operation, maintenance and repair of a facility, plant, equipment or system throughout its life cycle.

Generally it is prepared during construction and submitted upon completion of a new facility or major facility upgrade. eOMSI’s typically include asset information, staffing and budgeting information, supply support including critical spare parts, operating procedures, troubleshooting and diagnostic guides, extended warranty data, maintenance task frequencies and documentation, technical data, repair procedures and manufacturer’s product data. eOMSI data and document files are provided in electronic formats.

Equipment Tangible asset that is functionally complete for its intended purpose, durable, and non-expendable.

Facility A building or structure designed and created to serve a particular function.

Definition Description Fixed Burden Rate

(FBR)

The additional costs (expressed in percent of direct material cost) for ordering, handling, and stockpiling materials and repair parts. For example, if the offeror's Fixed Burden Rate for materials in the Base Period is 10% then:

$100,000.00 + ($100,000.00 x 10%) = $110,000.00

The Government will compensate the Contractor for the required parts and materials and not the total amount shown in Schedule of Indefinite Delivery Indefinite Quantity Work.

Frequency Of Service Annual (A). Services performed once during each 12-month period of the contract at intervals of 335 to 395 days.

Semiannual (SA). Services performed twice during each 12-month period of the contract at intervals of 160 to 200 calendar days.

Government Furnished Property (GFP)

Property in the possession of, or directly acquired by, the Government and subsequently furnished to the contractor for performance of a contract. Government furnished property includes, but is not limited to, spares and property furnished for repairs, maintenance, overhaul, or modification. Government furnished property also includes contractor acquired property if the contractor acquired property is a deliverable under a cost contract when accepted by the Government for continued use under the contract.

Infrastructure Condition Assessment Program

(ICAP)

A Navy automated data management program that utilizes historical asset lifecycle data and a structured assessment process to evaluate the condition facilities and their components.

Inspection A rigorous, detailed assessment of the condition of a facility performed to generate a fundable scope and cost estimate for prioritization and funding of maintenance and repair.

Job or Work Order An authorization for work that requires planning and estimating and has an individual line of accounting for financial and performance evaluation.

Maintenance And Repair

The preservation or restoration of a piece of equipment, system, or facility to such condition that it may be effectively used for its designated purposes. Maintenance/repair may be adjustment, overhaul, reprocessing, or replacement of constituent parts or materials that are missing or have deteriorated by action of the elements or usage, or replacement of the entire unit or system if beyond economical repair.

USMC MAXIMO A specially configured software version of MAXIMO®, a commercially available computerized maintenance management system (CMMS), adopted by NAVFAC for enterprise facility asset data management. The terms “MAXIMO”, “NAVFAC MAXIMO” or “Government’s MAXIMO” shall be used interchangeably in the document.

Performance Assessment

A method used by the Government to provide some measure of control over the quality of purchased goods and services received.

Performance Assessment Representative (PAR)

That individual designated by the KO to be responsible for the monitoring of Contractor performance.

Pre-Expended Bin Materials And Supplies

The minor materials and supplies that are incidental to the job, for which the total direct cost of any one material line item shown on the material estimate is $10.00 or less.

Examples of pre-expended bin materials and supplies include, but are not limited to, solder, lead, flux, electrical connectors, electrical tape, fuses, nails, screws, bolts, nuts, washers, spacers, masking tape, sand paper, solvent, cleaners, lubricants, grease, oil, rags, mops, glue, epoxy, spackling compound, joint tape, plumbers tape and compound, clips, welding rods, and touch up paint.

Property Administrator An authorized representative of the Contracting Officer who is responsible for administering contract property requirements, terms and conditions of the contract

Property Management Program

A Government program established for the purpose of reviewing and approving the Contractor’s Property Management Plan and System through performance of a system analysis whenever government property is in the possession of the Contractor.

Definition Description Quality Assurance

(QA)

The planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled.

Quality Control (QC) The observation techniques and activities used to fulfill requirements for quality.

R. S. Means A data collection and organization system developed by R. S. Means Company which can be used to prepare accurate, dependable construction estimates and budgets in a variety of ways. The Contractor shall use the latest edition. Material prices are based on a national average and computed labor costs are based on a 30-city national average. An estimate prepared using this data is called a "Means estimate"; data may simply be referred to as "Means".

Real Property Inventory Equipment (RPIE)

A Government owned or leased individual pieces of equipment, apparatus, or fixture that are essential to the function of the real property (i.e. plumbing, electrical, heating, cooling and elevators). It is physically attached to, integrated into, and built in or on the property.

Individual RPIE’s can be combined to make a CIMU to facilitate facilities management.

An individual RPIE can also be a CIMU if the equipment is complex enough to require its own management planning.

Response Time The time allowed the Contractor after initial notification of a work requirement to be physically on the premises at the work site with appropriate personnel, tools, equipment, and materials, ready to perform the work required.

Unit Priced Labor (UPL) Hour

The unit price bid by the Contractor to perform one hour of work-in-place. With the exception of direct material and construction equipment costs, the unit price includes all indirect and direct costs associated with performing work. The price includes the Contractor’s hourly composite trade wage, adjusted to allow for workforce productivity;

costs for pre-expended bin materials, union agreements, crew sizes, hand tools, payroll burdens and fringes, overtime, job (field) overhead (including clerical support, supervision, inspection, fees, taxes, licenses, permits, and insurance), general and administrative (home office) overhead, and profit. Additionally, time for job preparation, safety standby personnel, and similar indirect labor elements are included.

ATTACHMENT J-0200000-03

DIRECTIVES, INSTRUCTIONS, AND REFERENCES

Reference Title

ANSI/ISEA 107-2010 High Visibility Garment Standard

29 CFR 1910.120 Hazardous Materials - Hazardous waste operations and emergency response

29 CFR 1910.134 Personal Protective Equipment-Respiratory protection.

29 CFR 1926.16 Safety and Health Regulations for Construction

29 CFR 1926.59 Occupational Health and Environmental Controls - Hazard communication

40 CFR 247

Comprehensive Procurement Guideline for Products Containing Recovered Materials

DFARS 252.223-7004 Drug Free Work Force

EM 385-1-1 U.S. Army Corps of Engineers Safety and Health Requirements

E.O. 13423 Executive Order Strengthening Federal Environmental, Energy, and Transportation Management

FAR 52.223-2

Affirmative Procurement of Biobased Products under Service and Construction Contracts

FAR 52.223-3 Hazardous Material Identification and Material Safety Data Sheet

FAR 52.228-5 Insurance – Work On A Government Installation

FAR 52.246-4 Inspection of Services Fixed-Price

NFPA 10 Standard for Portable Fire Extinguishers

NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Operations

NFPA 51B Standard for Fire Prevention During Welding, Cutting and other Hot Work

NFPA 70 National Electric Code

NFPA 70E Standard for Electrical Safety in the Workplace

P.L. 91-596 Occupational Safety and Health Act

ATTACHMENT J-0200000-04

INVOICE FORM

NAVFAC 7300/30 NAVAL FACILITIES ENGINEERING SYSTEMS COMMAND

(Rev 2/01)

DUNS NO: ______________

1. CONTRACTOR’S INVOICE CAGE CODE NO: ______________

From: ____________________________________ Invoice Date: ______________ ____________________________________ Invoice Number: ______________ POC/Telephone/email for this invoice: __________________________________________________________ To: Contract Specialist: _____________________________________________________________________ Below is a Statement of Performance under Contract N40085-_______________Task Order: ______________ For _____________________________ at _____________________________________________________

The enclosure provides breakdown of this statement of performance.

A. Total value of contract/task order through change _________ ________________ B. Percentage of performance complete _________ ________________ C. Value of completed performance _______________ D. Less total of prior payments _______________ E. Amount of this invoice _______________

Signature and Title: ______________________________________________ Date: Signature of Authorized Representative

2. FIRST ENDORSEMENT Receipt and Acceptance Certification From: _________________________________________________________________ To: _________________________________________________________________

1. Payment is recommended as follows:

A. Amount of work completed to (date) ______________ ___________________ B. Less:

Retention _____________ Other Deductions: _____________ __________________

C. Subtotal ___________________ D. Less previous payments ___________________ E. Certified amount for payment # _______ Final on TO# _________ ___________________ F. Elapsed contract time (if applicable) ____________________ G. Responsible Certifying UIC ____________________ H. Invoice Receipt Date ____________________ I. Material/Services Receipt Date ____________________ J. Material/Services Acceptance Date ____________________ K. Date forwarded to paying office ____________________ L. I certify this amount is correct and payment i8s recommended.

Signature: ________________________________________ Date: _________________________ Signature of Authorized Representative

Name and Title (Typed): ______________________________________________________ Phone and address: ______________________________________________________

3. PROMPT PAYMENT CERTIFICATION

I certify that the accounting data provided is accurate, funds have been obligated in appropriate accounting system and changes have been applied to the appropriate accounting classification reference number (ACRN), available funds have been decremented for the amount approved for disbursement and will not be de-obligated and the above invoice is correct and proper for payment.

Signature: _____________________________ Date: __________________ Signature of Authorized Representative

Name and Title (typed): ______________________________________________________ Phone and address: _________________________________________________________ Line(s) of accounting to be used for this invoice (include appropriate Line Item # (CLIN, SLIN, OR ACRN, etc)

Contractor Significant Incident Report (CSIR) 1

ATTACHMENT J-0200000-05-1

er______________________________

Initial Report

Follow-up Report

Final Report

Contractor Significant Incident Report (CSIR)

1. General Information Contracting Activity/ROICC Office:

Accident Classification:

Injury Fatality Environment Procedural Issues Lessons Learned

Illness Property Damage Oth

Involving:

Confined Space Equip/Mrt Ver/Mat Handling (Heavy Construction Equip.) Hazardous Material

Crane and Rigging Equip/Mrt Ver/Mat Handling (Material Handling) Trenching/Excavation

Diving Equip/Mrt Ver/Mat Handling (Man-Lift/Elevated Platform) Waterfront/Marine

Demolition/Renovation Fall from Ladder Fall from Scaffold Other_

Electrical Fall from Roof Fire

2. Personal Information Name (Last, First, MI): Age: Sex:

Job Title/Description: Employed By:

Supervisor Name (Last, First, MI) & Title: Was the person trained to perform this activity/task?

Yes No

What type of training was received (OJT, classroom, etc)?

Date of the most recent formal training and topics discussed?

3. Witness Information Witness #1: Name (Last, First, MI): Job Title/Description:

Employed By: Supervisor Name (Last, First, MI):

Witness #2: Name (Last, First, MI): Job Title/Description:

Employed By: Supervisor Name (Last, First, MI):

Contractor Significant Incident Report (CSIR) 1

Additional Witnesses: Yes No (List any additional witnesses on a separate sheet and attach.)

Contractor Significant Incident Report (CSIR) 2

4. Contract Information Type of Contract:

A/E

JOC

BOS

RAC

CLEAN

Service

Construction

Other

Design Build

FSCC

FSSC

Contract Number & Title: Industrial Group & Industrial Type:

Prime Contractor Name/Address/Phone & Fax No:

Safety Manager (Last, First, MI):

Insurance Carrier:

Sub Contractor Name/Address/Phone & FAX No:

Safety Manager (Last, First, MI):

Insurance Carrier:

5. Accident Description Date of Accident: Time of Accident: Exact Location of Accident:

Describe the accident in detail in your words: (Use the back of page if you need additional space)

Direct Cause(s) of Accident:

Contractor Significant Incident Report (CSIR) 3

Indirect Cause(s) of Accident:

Action(s) taken to prevent re-occurrence or provide on-going corrective actions:

Corrective Action Beginning Date: Anticipated Completion Date:

Personal Protective Equipment:

Available and used

Not related to Mishap

List PPE Used:

Available and not used

Wrong PPE for job

Not Required

Type of Construction Equipment (Make, Model, Serial #, VIN#) Involved:

Was Hazardous Material Spilled/Released?

Please List Hazardous Material(s) Involved:

Yes No

Who provided first aid or cleanup of mishap site?

Any blood-borne pathogen exposure, other than EMTs?

Who?

Yes No

List OSHA and WM-385-1-1 standards that were violated:

Was site secured and witness statements taken immediately?

By Whom?

Yes No

Contractor Significant Incident Report (CSIR) 4

6. Injury Illness/Fatality Information Severity of Injury/Illness:

Fatality

Temporary Disabillity

Permanent Total Disability

Permanent Partial Disability

Lost Workday Case Involving Days Away From Work

Recordable Workday Case Involving Restricted Duty

Other Recordable Case Recordable First Aid Case

Non-Recordable Case No Injury

Estimated Days Lost: Estimated Days Hospitalized: Estimated Days Restricted Duty:

List Primary Body Part Affected: List Other Body Part(s) Affected:

Nature of Injury/Illness for Primary Body Part (Examples: Amputation, Burn, Hernia):

Type of Accident (Examples: Fall same level, Lifting, Bitten, Exerted):

Source of Accident (Examples: Crane, Carbon Monoxide, Ladder, Welding Equipment):

7. Casual Factors (Explain answers on supplementary sheet) Design – Design of facility, workplace, or equipment was a factor? Yes No

Inspection/Maintenance – Inspection & Maintenance procedures were a factor? Yes No

Persons Physical Condition – In your opinion, the physical condition of the person was a factor?

Yes No

Operation Procedures – Operating procedures were a factor? Yes No

Job Practices – One or more job safety/health practices not being followed when the accident occurred contributed to the accident?

Yes No

Human Factors – One or more human factors, such as a person’s size or strength contributed to the accident?

Yes No

Environmental Factors – Heat, cold, dust, sun, glare, etc., contributed to the accident?

Yes No

Chemical and Physical Agent Factors – Exposure to chemical agents, such as dust, fumes, mist, vapors, or physical agents such as noise, radiation, etc., contributed to the accident?

Yes No

Office Factors – Office setting such as lifting office furniture, carrying, stooping, contributed to the accident?

Yes No

Support Factors – Inappropriate tools/resources were provided to perform the task?

Yes No

PPE – Improper selection, use or maintenance of PPE contributed to the accident?

Yes No

Drugs/Alcohol – In your opinion, were drugs or alcohol a factor? Yes No

Job Hazard Analysis – The lack of an adequate (IAW-EM-385-1-1 Sec 01.A) activity hazard analysis was a contributing factor.

Yes No

Job Hazard Analysis – JHA was not site specific and/or did not address the type of work/operations performed when the mishap occurred.

Yes No

Management – A lack of adequate supervision contributed to the accident. Yes No

Management – Inadequate information was provided at pre con meeting. Yes No

Contractor Significant Incident Report (CSIR) 5

8. OSHA Information Date OSHA was Notified: Date(s) of Investigation: Date of citation:

(Attach Copy) Dollar amount of Penalties:

9. Report Preparer Name (Last, First, MI): Date of Report:

Title:

Employer:

Phone #:

Signature:

Contractor Significant Incident Report (CSIR) Instructions 1

CONTRACTOR SIGNIFICANT INCIDENT REPORT (CSIR) INSTRUCTIONS

Complete Sections Appropriate to Incident (Rev. 06/02).

NOTE: THE ATTACHED CSIR FORM IS TO BE USED BY CONTRACTORS TO RECORD THE

RESULTS OF THEIR ACCIDENT/INCIDENTS INVESTIGATIONS AND SHALL BE PROVIDED TO THE

CONTRACTING OFFICER WITHIN THE REQUIRED TIMEFRAMES.

GENERAL. Complete a separate report for each person who was injured in the accident. A report needs to be completed for all OSHA recordable accidents, property damage in excess of $2000.00 (This amount is for record purposes only. GOV is not required to enter property damage reports into FAIR database if it is less than $10,000.00.), WHE accidents, or near miss/high visibility mishaps. Please type or print legibly. Appropriate items shall be marked with an “X” in box(es), non-applicable sections shall be marked “N/A”. If additional space is needed, provide the information on a separate sheet of paper and attach to the completed form.

Mark the report:

INITIAL – If this form is being used as initial notification of a Fatality or High Visibility Mishap. The initial form is due within 4 hours of a serious accident. A form marked ‘Follow-up’ or ‘Final’ is required within 5 days.

FOLLOW-UP – If you are providing additional information on a report previously submitted.

FINAL – If you are providing a completed report and expect no changes.

SECTION 1 – GENERAL INFORMATION

CONTRACTING ACTIVITY/ROICC OFFICE - Enter the name and address of the Contracting Office administering the contract under which the mishap took place (e.g. ROICC MCBH, ROICC NORFOLK, PWC GUAM, etc.).

ACCIDENT CLASSIFICATION - INJURY/ILLNESS/FATALITY/PROPERTY DAMAGE/-PROCEDURAL ISSUES/- ENVIRONMENTAL/LESSONS LEARNED/OTHER – Mark the appropriate block(s) if the incident resulted in any of these conditions.

INVOLVING - If the mishap involved any of the conditions listed under “Involving” mark the appropriate box(es). Specific questions associated with each of these conditions are available from the Contracting Officer to assist you in your investigation. When these questions are used they shall be attached as part of this report.

SECTION 2 - PERSONAL INFORMATION

NAME - Enter last name, first name, middle initial of person involved.

AGE - Enter age.

SEX - Enter M for Male and F for Female.

JOB TITLE/DESCRIPTION - Enter the job title/description assigned to the injured person (e.g. carpenter, laborer, surveyor, etc.).

EMPLOYED BY - Enter employment company name of the person involved.

SUPERVISOR’S NAME & TITLE - Enter name and title of the immediate supervisor.

WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK? - For the purpose of this section “trained” means the person has been provided the necessary information (either formal and/or on-the-job (OJT) training) to competently perform the activity/task in a safe and healthful manner.

TYPE OF TRAINING - Indicate the specific type of training (classroom or on-the-job) that the injured person received before the accident happened.

DATE OF MOST RECENT FORMAL TRAINING/TOPICS DISCUSSED - Enter the month, day, and year of the last formal training completed that covered the activity/task being performed at the time of the accident. List topics that were discussed at the training identified above.

SECTION 3 - WITNESS INFORMATION

The following applies to Witness #1 and Witness #2:

WITNESS NAME - Enter last name, first name, middle initial of the witness.

JOB DESCRIPTION/TITLE - Enter the job title/description assigned to the witness (e.g. carpenter, laborer, surveyor, etc.).

EMPLOYED BY - Enter the name of the employment company of the witness.

SUPERVISORS NAME - Enter name of immediate supervisor of the witness.

ADDITIONAL WITNESSES - Provide same information, as above, for each witnesses. Use additional pages if necessary.

SECTION 4 - CONTRACTOR INFORMATION

TYPE OF CONTRACT - Mark appropriate box. A/E means architect/engineer. If “OTHER” is marked, specify type of contract on line provided.

CONTRACT NUMBER/TITLE - Enter complete contract number and tile of prime contract (e.g. N62477-85-C-0100, 184 Pearl City Hsg. Revitalization).

CONSTRUCTION INDUSTRIAL GROUP AND INDUSTRIAL TYPE – This is the type of construction that will be done at this project.

Contractor Significant Incident Report (CSIR) Instructions 2

1. First, you must choose the Industrial Group. You have 4 choices to choose from: (NOTE! Review of the Industrial Types below and knowing what the projects scope of work is will assist you in deciding what the Industrial Group should be.)

a. Buildings

b. Heavy Industrial

c. Infrastructure

d. Light Industrial

2. Once you have chosen the Industrial Group, you now select the Industrial Type. You have multiple choices under each Group, chose the one you feel fits the project most closely because on most projects there won’t be an exact match:

a. Buildings:

(1) Communications Ctr.

(2) Dormitory/Hotel

(3) High-rise Office

(4) Hospital

(5) Housing

(6) Laboratory

(7) Low-rise Office

(8) Maintenance Facility

(9) Parking Garage

(10) Physical Fitness Ctr.

(11) Restaurant/Nightclub

(12) School

(13) Warehouse

b. Heavy Industrial:

(1) Chemical Mfg.

(2) Electrical (Generating)

(3) Environmental

(4) Metals Refining/Processing

(5) Mining

(6) Natural Gas Processing

(7) Oil Exploration/Production

(8) Oil Refining

(9) Pulp and Paper

c. Infrastructure:

(1) Airport

(2) Electrical Distribution

(3) Flood Control

(4) Highway

(5) Marine Facilities

(6) Navigation

(7) Rail

(8) Tunneling

(9) Water/Wastewater

d. Light Industrial:

(1) Automotive Assembly/Mfg.

(2) Consumer Products Mfg.

(3) Foods

(4) Microelectronics Mfg.

(5) Office Products Mfg.

(6) Pharmaceuticals Mfg.

CONTRACTOR’S NAME/ADDRESS/PHONE NUMBER

(1) PRIME - Enter the exact name (title of firm), address, phone and fax numbers of the prime contractor.

(2) SUBCONTRACTOR - Enter the exact name, address, phone and fax numbers of any subcontractor involved in the accident.

SAFETY MANAGER’S NAME

(1) PRIME - Enter the name of the prime contractor safety manager.

(2) SUBCONTRACTOR - Enter the name of the subcontractors safety manager.

INSURANCE CARRIER

(1) PRIME - Enter the exact name/title of the prime’s insurance company. Policy number not required.

(2) SUBCONTRACTOR - Enter the exact name of the subcontractor’s insurance company. Policy number not required.

SECTION 5 - ACCIDENT DESCRIPTION

DATE OF ACCIDENT - Enter the month, day, and year of accident.

TIME OF ACCIDENT - Enter the local time of accident in military time. Example: 14:30 hrs (not 2:30 p.m.).

EXACT LOCATION OF ACCIDENT - Enter facts needed to locate the accident scene (installation/project name, building/room number, street, direction and distance from closest landmark, etc.).

DESCRIBE THE ACCIDENT IN DETAIL. Fully describe the accident in the space provided. If property damage involved, give estimated dollar amount of damage and/or repair costs involved. If additional space is needed continue on a separate sheet and attach to this report. Give the sequence of events that describe what happened leading up to and including the accident. Fully identify personnel and equipment involved and their role(s) in the accident. Ensure that relationships between personnel and

Contractor Significant Incident Report (CSIR) Instructions 3 equipment are clearly specified. Ensure questions below regarding direct cause(s), indirect cause(s), and actions taken are answered. NOTE! Review questions in Section 7 below before completing.

DIRECT CAUSE(S) - The direct cause is that single factor which most directly lead to the accident. See examples below.

INDIRECT CAUSE(S) - Indirect cause are those factors, which contributed to, but did not directly initiate the occurrence of the accident.

Examples for Direct and Indirect Cause:

1. Employee was dismantling scaffold and fell 12 feet from unguarded opening.

Direct cause: Failure to provide fall protection at elevation Indirect causes: Failure to enforce safety requirements: improper training/motivation of employee (possibility that employee was not knowledgeable of fall protection requirements or was lax in his attitude toward safety); failure to ensure provision of positive fall protection whenever elevated; failure to address fall protection during scaffold dismantling in phase hazard analysis.

2. Private citizen had stopped his vehicle at intersection for red light when vehicle was struck in rear by contractor vehicle. (note contractor vehicles was in proper safe working condition.)

Direct cause: Failure of contractor driver to maintain control of and stop contractor vehicle within safe distance.

Indirect cause: Failure of employee to pay attention to driving (defensive driving).

ACTION(S) TAKEN TO PREVENT RE-OCCURRENCE OR PROVIDE ON-GOING CORRECTIVE ACTIONS. Fully describe all the actions taken, anticipated, and recommended to eliminate the cause(s) and prevent reoccurrence of similar accidents/illnesses.

Continue on back or additional sheets of paper if necessary to fully explain and attach to the complete report form.

CORRECTIVE ACTION DATES -

(1) Beginning - Enter the date when the corrective action(s) identified above will begin.

(2) Anticipated Completion - Enter the date when the corrective action(s) identified above will be completed.

PERSONAL PROTECTIVE EQUIPMENT (PPE) - Mark appropriate box(es) and list PPE which was being used by the injured person at the time of the accident (e.g. protective clothing, shoes, glasses, goggles, respirator, safety belt, harness, etc.)

TYPE OF CONTRACTOR EQUIPMENT - Enter the Serial Number, Model Number and specific type of equipment involved in the mishap (e.g. dump truck (off highway), crane (rubber tire), pump truck (concrete), etc.).

WAS HAZARDOUS MATERIAL SPILLED/RELEASED? - Mark appropriate block and list name(s) of any reportable quantities of hazardous materials spilled/released during the mishap.

WHO PROVIDED FIRST AID OR CLEAN-UP OF MISHAP SITE? - List name(s) of individual(s) and employer, if known.

ANY BLOOD-BORNE PATHOGEN EXPOSURE, OTHER THAN EMT? - Mark appropriate block and list name(s) of individual(s) and employer, if known.

LIST OSHA AND/OR EM 385-1-1 STANDARDS THAT WERE VIOLATED. - Self explanatory.

WAS SITE SECURED AND WITNESS STATEMENT TAKEN IMMEDIATELY? - Mark appropriate block and list by whom.

SECTION 6 - INJURY/ILLNESS/FATALITY INFORMATION

SERVERITY OF INJURY/ILLNESS – Mark appropriate box.

ESTIMATED DAYS LOST - Enter the estimated number of workdays the person will lose from work. Update when final data is known.

ESTIMATED DAYS HOSPITALIZED - Enter the estimated number of workdays the person will be hospitalized. Update when final data is known.

ESTIMATED DAYS RESTRICTED DUTY - Enter the estimated number of workdays the person, as a result of the accident, will not be able to perform all of their regular duties. Update when final data is known.

BODY PART(S) AFFECTED - Enter the most appropriate primary and when applicable, secondary, etc. body part(s) affected (e.g.

arm: wrist: abdomen: single eye; jaw : both elbows: second finger: great toe: collar bone: kidney, etc.).

NATURE OF INJURY/ILLNESS FOR PRIMARY BODY PART - Enter the most appropriate nature of injury/illness (e.g. amputation, back strain, dislocation, laceration, strain, asbestosis, food poisoning, heart conditions, etc.).

TYPE AND SOURCE OF INJURY/ILLNESS - Type and Source Codes are used to describe what caused the incident.

(1) TYPE Code stands for an “Action” (Example: Worker, installing conduit, lost his balance and fell five feet from a ladder.

Type Code: Fell different levels”.) Select the most appropriate Type of injury from the list below:

TYPE OF INJURY/ILLNESS

STRUCK

BY/AGAINST

CONTACTED

CONTACTED WITH (INJURED PERSON MOVING)

CONTACTED BY (OBJECT WAS MOVING)

FELL, SLIPPED, TRIPPED

SAME LEVEL/DIFFERENT LEVEL/NO FALL

EXERTED

LIFTED, STRAINED BY (SINGLE ACTION)

STRESSED BY (REPEATED ACTION)

CAUGHT

ON/IN/BETWEEN

EXPOSED

INHALED/INGESTED/ABSORBED/EXPOSED TO

PUNCTURED, LACERATED

PUNCTURED BY/CUT BY/STUNG BY/BITTEN BY

TRAVELING IN

(2) SOURCE Code stands for an “object or substance.” (Example: Worker, installing conduit, lost his balance and fell five feet from a ladder. Source Code: “Ladder”.) Select the most appropriate Source of injury from the list below:

Contractor Significant Incident Report (CSIR) Instructions 4

SOURCE OF INJURY/ILLNESS

BUILDING OR WORKING AREA

WALKING/WORKING AREA

STAIRS/STEPS

LADDER

FURNITURE

BOILER/PRESSURE VESSEL

EQUIPMENT LAYOUT

WINDOWS/DOORS

ELECTRICITY

DUST, VAPOR, ETC.

DUST (SILICA, COAT, ETC.)

FIBERS

ASBESTOS

GASES

CARBON MONOXIDE

MIST, STEAM, VAPOR, FUME

WELDING FUMES

PARTICLES (UNIDENTIFIED)

ENVIRONMENT CONDITION CHEMICAL, PLASTIC, ETC.

TEMPERATURE EXTREME (INDOOR) DRY CHEMICAL - CORROSIVE

WEATHER (ICE, RAIN, HEAT, ETC.) DRY CHEMICAL - TOXIC

FIRE, FLAME, SMOTE (NOT TABACCO) DRY CHEMICAL - EXPLOSIVE

NOISE DRY CHEMICAL - FLAMMABLE

RADIATION LIQUID CHEMICAL - CORROSIVE

LIGHT LIQUID CHEMICAL - TOXIC

VENTILATION LIQUID CHEMICAL - EXPLOSIVE

TOBACCO SMOKE LIQUID CHEMICAL - FLAMMABLE

STRESS (EMOTIONAL) PLASTIC

CONFINED SPACE WATER

MEDICINE

MACHINE OR TOOL INANIMATE OBJECT

HAND TOOL (POWERED: SAW, GRINDER, ETC.) BOX, BARREL, ETC.

HAND TOOL (NON POWERED) PAPER

MECHANCIAL POWER TRANSMISSION APPARATUS METAL ITEM, MINERAL

GUARD, SHIELD (FIXED, MOVEABLE, INTERLOCK) NEEDLE

VIDEO DISPLAY TERMINAL GLASS

PUMP, COMPRESSOR, AIR PRESSURE TOOL SCRAP, TRASH, WOOD

HEATING EQUIPMENT FOOD

WELDING EQUIPMENT CLOTHING, APPAREL, SHOES

MACHINE OR TOOL INANIMATE OBJECT

HAND TOOL (POWERED: SAW, GRINDER, ETC.) BOX, BARREL, ETC.

HAND TOOL (NON POWERED) PAPER

MECHANCIAL POWER TRANSMISSION APPARATUS METAL ITEM, MINERAL

GUARD, SHIELD (FIXED, MOVEABLE, INTERLOCK) NEEDLE

VIDEO DISPLAY TERMINAL GLASS

PUMP, COMPRESSOR, AIR PRESSURE TOOL SCRAP, TRASH, WOOD

HEATING EQUIPMENT FOOD

WELDING EQUIPMENT CLOTHING, APPAREL, SHOES

VEHICLE ANIMATE OBJECT

AS DRIVER OF PRIVATELY OWNED, RENTAL VEH. DOG

AS PASSENGER OF PRIVATELY OWNED, RENTAL VEH. OTHER ANIMAL

DRIVER OF GOVERNMENT VEHICLE PLANT

PASSENGER OF GOVERNMENT VEHICLE INSECT

COMMON CARRIER (AIRLINE, BUS, ETC.) HUMAN (VIOLENCE)

AIRCRAFT (NOT COMMERCIAL) HUMAN (COMMUNICABLE DISEASE)

BOAT, SHIP, BARGE BACTERIA, VIRUS (NOT HUMAN CONTACT)

MATERIAL HANDLING EQUIPMENT PERSONAL PROTECTIVE EQUIPMENT

EARTHMOVER (TRACTOR, BACKHOE, ETC.) PROTECTIVE CLOTHING, SHOES, GLASSES, GOGGLES

CONVEYOR (FOR MATERIAL AND EQUIPMENT) RESPIRATOR, MASK

ELEVATOR, ESCALATOR, PERSONNEL HOIST DIVING EQUIPMENT

HOIST, SLING CHAIN, JACK SAFETY BELT, HARNESS

CRANE PARACHUTE

FORKLIFT

HANDTRUCK , DOLLY

SECTION 7 - CAUSAL FACTORS

Review thoroughly. Answer each question by marking the appropriate block. NOTE! If any answer is yes, explain in section 5 above.

(1) DESIGN - Did inadequacies associated with the building or work site play a role? Would an improved design or layout of the equipment or facilities reduce the likelihood of similar accidents? Were the tools or other equipment designed and intended for the task at hand?

Contractor Significant Incident Report (CSIR) Instructions 5

(2) INSPECTION/MAINTENANCE - Did inadequately or improperly maintained equipment, tools, workplace, etc., create or worsen any hazards that contributed to the accident? Would better equipment, facility, work site or work activity inspections have helped avoid the accident?

(3) PERSONS PHYSICAL CONDITION - Do you feel that the accident would probably not have occurred if the employee was in “good” physical condition? If the person involved in the accident had been in better physical condition, would the accident have been less severe or avoided altogether? Was overexertion a factor?

(4) OPERATION PROCEDURES - Did lack of or inadequacy within established operating procedures contribute to the accident? Did any aspect of the procedures introduce any hazard to, or increase the risk associated with the work process?

Would establishment or improvement of operating procedures reduce the likelihood of similar accidents?

(5) JOB PRACTICES - Were any of the provision of the Safety and Health Requirements Manual (EM 385-1-1) violated? Was the task being accomplished in a manner which was not in compliance with an established job hazard analysis or activity hazard analysis? Did any established job practice (including EM 385-1-1) fail to adequately address the task or work process?

Would better job practices improve the safety of the task?

(6) HUMAN FACTORS - Was the person under undue stress (either internal or external to the job)? Did the task tend toward overloading the capabilities of the person: i.e., did the job require tracking and reacting to many external inputs such as displays, alarms, or signals? Did the arrangement of the workplace tend to interfere with efficient task performance? Did the task require reach strengths, endurance, agility, etc., at or beyond the capabilities of the employee? Was the work environment ill-adapted to the person? Did the person need more training, experience, or practice in doing the task? Was the person inadequately rested to perform safely?

(7) ENVIRONMENTAL FACTORS - Did any factors such as moisture, humidity, rain, snow, sleet, hail, ice, fog, cold, heat, sun temperature changes, wind, tides, floods, currents, terrain; dust, mud, glare, pressure changes, lighting, etc., play a part in the accident?

(8) CHEMICAL AND PHYSICAL AGENT FACTORS - Did exposure to chemical agents (either single shift exposure or long-term exposure such as dusts, fibers, (asbestos, etc.), silica, gases (carbon, monoxide, chlorine, etc.), mists, steam, vapors, fumes, smoke, other particulates, liquid or dry chemicals that are corrosive, toxic, explosive or flammable, by-products of combustion or physical agents such as noise, ionizing radiation, non-ionizing radiation (UV radiation created during welding, etc.) contribute to the accident/incident?

(9) OFFICE FACTORS - Did the fact that the accident occurred in an office setting or to an office worker have a bearing on its cause? For example, office workers tend to have less experience and training in performing tasks such as lifting office furniture. Did physical hazards within the office environment contribute to the hazard?

(10) SUPPORT FACTORS - Was the person using an improper tool for the job? Was inadequate time available or utilized to safely accomplish the task? Were less than adequate personnel resources (in terms of employee skills, number of workers, and adequate supervision) available to get the job done properly? Was funding available, utilized and adequate to provide proper tools, equipment, personnel, site preparation, etc.

(11) PERSONAL PROTECTIVE EQUIPMENT - Did the person fail to use appropriate personal protective equipment (gloves, eye protection, hard-toed shoes, respirator, etc) for the task or environment? Did protective equipment provided or worn fail to provide adequate protection from the hazard(s)? Did lack of or inadequate maintenance of protective gear contribute to the accident?

(12) DRUGS/ALCOHOL - Is there any reason to believe the person’s mental or physical capabilities, judgment, etc., were impaired or altered by the use of drugs or alcohol? Consider the effects of prescription medicine and over the counter medications as well as illicit drug use. Consider the effect of drug or alcohol induced “hangovers”.

(13) JOB/ACTIVITY HAZARD ANALYSIS - Was a written Job/Activity Analysis completed for the task being performed at the time of the accident? If one was made, did it address the hazard adequately or does it need to be updated? If none made, will one be made? These may also need to be addressed in the Corrective Actions Taken section. Mark the appropriate box. If one was made, attach a copy of the analysis to the report.

(14) MANAGEMENT - Did the lack of supervisor or management support play a part in the mishap? Mark the appropriate box.

SECTION - 8 OSHA INFORMATION - Complete this section if applicable

SECTION 9 - REPORT PREPARER

Providing a completed CSIR to the Contracting Officer is the PRIME CONTRACTOR’S RESPONSIBILITY. Enter the name, date of report, title, employer, phone number and signature of person completing the accident report and provide it to the Contracting Officer, or his representative, responsible for oversight of that contractor activity. NOTE! If prepared by other than the Prime Contractor, a person employed by the Prime Contractor must sign that they have reviewed and concur with the report and it’s findings (e.g. company owner, project supervisor/foreman, Safety Officer, etc.).

ATTACHMENT J-0200000-05-2

MOTOR VEHICLE ACCIDENT REPORT

DATE:

YEAR/MAKE:

TIME: MODEL :

DRIVER :

HOME ADDRESS:

TELEPHONE:

REGISTRATION NUMBER OR NAME:

DESCRIPTION OF ACCIDENT:

SIGNATURE:

(CONTINUE ON BACK OR SEPARATE PAGE IF REQUIRED)

ATTACHMENT J-0200000-05-3

SPILL RESPONSE FORM

MCBCL/MCASNR SPCC State Notification of Discharge Report (POL's) Subj· ln•t•tl�llon POC/Phone Numbff: John H.1m�1on ACAS S..tll!MSOr Vl0-151-1482

I. Oate and Tima When AotNse Occur....utlitcD•ered

2. Ac1Mty/Rspanalble Pa,ty Originating Rein••

2a. Addre•• or Attl)O(IIIDi. Part)'

3. Source of Releaae (Storage Arn. Shop, Vltlllclt, tie)

•. Location or Splll (Bldg, Highway, Range, etc)

5, Oullntlly Aeleuecf (Gallona/1.lten, PoundllKJlogromaJ • It Unkn-n, lndlcalt Size of Conlamlneled Are•

6. T'll)e ol Subtlance ReleHod

7. Cantnln..- l1wolvtc1 (Drum, Bag, Storage Ttnk, l!lc)

a. Samples Taken (Val/No; Speclty Analyau ReqUHtecl/Pe,lo,med)

9. Cause of Rel•Ht

1 O. Reitan Scana Dnacrlpllon (Contanilnlted Arte, Path ofAtl .. at, etc) t I, Documont the Action TtkffllPJannecl to Mitigate the fleletH

12. On,SceM Wttlller/Wlnd (Temp, Humidity, Wind Vtloclt•. VislblMtw. etc:I

13. Aten Thrttttned/D;lmaged (Buch, Well1nda, W.itr lnlak., Aquifer. elc)

14. Polcnllal Dang..-. (Fire. E•ploalan, Toxic Vapor, ele)

IS. NoUllcaUon• Mada (NAC, Ccasl Guard MSO, EPA.

Stale. Local Agfflcy. etc) II. Ttlephonlc Report to NRC WHIWH not mada (NAC POC/Repon Numbffl

17, POC for A--1 (Peraon, AcHvlty. Phone Numbar)

11. Documeftt Any OU..r AtltVlnt lnlormallon ..-1nlng lotlltRtltlle

Document \ht Ptt1enca of FnNI Product CH Kno>m)

State how \he Aetuae w .. Dlsco•med

"'• Th•lr Any W•ler Supply Walla Whhln 1,500 Foat ol lhe t Yn, How Many Waler Supply Wtlll are within 1,liOO '"' >I lheAeliraaa

'fas any surf•c• water Impacted or the spill wllhln 100 feel ,r leH al any surface w,1.,7

.alllud• and Longlluda of Release Lautudt I I

Longltudt l (Decimal (DeclfMI

.,_,, .. 1 n...,, ... 1 Nreellon1 to Ina splll site

Mlp Attached

ATTACHMENT J-0200000-05-4

CONTRACTOR HAZARDOUS MATERIAL INVENTORY LOG

Title: Landscaping & Vegetation Clearing N40085-22-Q-2996 New River Air Station MCB Camp Lejeune NC

Rev. Jan 2018 1

SENSITIVE INFORMATION

DISCLOSURE LIMITATIONS AS OUTLINED IN FAR 2.101 & 3.104 APPLY

J-0200000-06

ATTACHMENT C

TECHNICAL EXPERIENCE FORM

1. OFFEROR:

2. CONTRACT NUMBER/TASK ORDER:

3. PROJECT TITLE AND LOCATION:

4. PROJECT DESCRIPTION (add lines as necessary):

5. ROLE (CHECK ONE): Prime Contractor________ Subcontractor________

6. PERCENTAGE OF WORK SELF-PERFORMED BY THE OFFEROR:

7. PROJECT LOCATION:

8. ORGINAL CONTRACT AMOUNT:

9. FINAL CONTRACT AMOUNT:

10. AWARD DATE:

11. FINAL COMPLETION DATE:

12. CUSTOMER POINT OF CONTACT:

a. NAME /TITLE/ORG:

b. PHONE NUMBER:

c. EMAIL ADDRESS:

Rev Jan 2018 2

J-0200000-07

1. The NAVFAC Form PPQ shall be utilized for all evaluations that require a Past Performance Questionnaire (PPQ).

2. Solicitations

Solicitation Submittal Requirements: IF A COMPLETED CPARS EVALUATION IS AVAILABLE, IT SHALL BE SUBMITTED WITH THE PROPOSAL. IF THERE IS NOT A COMPLETED

CPARS EVALUATION, the Past Performance Questionnaire (PPQ) included in the solicitation is provided for the offeror or its team members to submit to the client for each project the offeror includes in its proposal for Factor 1, Technical Experience Attachment C. AN OFFEROR

SHALL NOT SUBMIT A PPQ WHEN A COMPLETED CPARS IS AVAILABLE.

IF A CPARS EVALUATION IS NOT AVAILABLE, ensure correct phone numbers and email addresses are provided for the client point of contact. Completed PPQs should be submitted with your proposal. If the offeror is unable to obtain a completed PPQ from a client for a project(s) before proposal closing date, the offeror should complete and submit with the proposal the first page of the PPQ (Attachment D), which will provide contract and client information for the respective project(s). Offerors should follow-up with clients/references to ensure timely submittal of questionnaires. If the client requests, questionnaires may be submitted directly to the Government's point of contact, Benjamin (Ashley) Bryan via email at benjamin.a.bryan.civ@us.navy.mil and Regenia Guest, via email at regenia.d.guest@navy.mil prior to proposal closing date. Offerors shall not incorporate by reference into their proposal PPQs or CPARS previously submitted for other RFPs. However, this does not preclude the Government from utilizing previously submitted PPQ information in the past performance evaluation.

Rev. Apr 2017 3

ATTACHMENT D

NAVFAC/USACE PAST PERFORMANCE QUESTIONNAIRE (Form PPQ-0)

CONTRACT INFORMATION (Contractor to complete Blocks 1-4)

1. Contractor Information Firm Name: CAGE Code:

Address: Entity Identifier Number:

Phone Number:

Email Address:

Point of Contact: Contact Phone Number:

2. Work Performed as: Prime Contractor Sub Contractor Joint Venture Other (Explain) Percent of project work performed:

If subcontractor, who was the prime (Name/Phone #):

3. Contract Information Contract Number:

Delivery/Task Order Number (if applicable):

Contract Type: Firm Fixed Price Cost Reimbursement Other (Please specify):

Contract Title:

Contract Location:

Award Date (mm/dd/yy):

Contract Completion Date (mm/dd/yy):

Actual Completion Date (mm/dd/yy):

Explain Differences:

Original Contract Price (Award Amount):

Final Contract Price (to include all modifications, if applicable):

Explain Differences:

4. Project Description:

Complexity of Work High Med Routine How is this project relevant to project of submission? (Please provide details such as similar equipment, requirements, conditions, etc.)

CLIENT INFORMATION (Client to complete Blocks 5-8)

5. Client Information Name:

Title:

Phone Number:

Email Address:

6. Describe the client’s role in the project:

7. Date Questionnaire was completed (mm/dd/yy):

8. Client’s Signature:

NOTE: NAVFAC REQUESTS THAT THE CLIENT COMPLETES THIS QUESTIONNAIRE AND SUBMITS DIRECTLY BACK TO THE OFFEROR. THE OFFEROR WILL SUBMIT THE COMPLETED QUESTIONNAIRE TO NAVFAC WITH THEIR PROPOSAL, AND MAY DUPLICATE THIS QUESTIONNAIRE FOR FUTURE SUBMISSION ON NAVFAC SOLICITATIONS.

CLIENTS ARE HIGHLY ENCOURAGED TO SUBMIT QUESTIONNAIRES DIRECTLY TO THE OFFEROR. HOWEVER, QUESTIONNAIRES MAY BE SUBMITTED DIRECTLY TO NAVFAC. PLEASE CONTACT THE OFFEROR FOR NAVFAC POC INFORMATION. THE GOVERNMENT RESERVES THE RIGHT TO VERIFY ANY AND ALL INFORMATION ON

THIS FORM.

Rev. Apr 2017 4

ADJECTIVE RATINGS AND DEFINITIONS TO BE USED TO BEST REFLECT

YOUR EVALUATION OF THE CONTRACTOR’S PERFORMANCE

RATING DEFINITION NOTE

(E) Exceptional Performance meets contractual requirements and exceeds many to the Government/Owner’s benefit.

The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective.

An Exceptional rating is appropriate when the Contractor successfully performed multiple significant events that were of benefit to the Government/Owner. A singular benefit, however, could be of such magnitude that it alone constitutes an Exceptional rating. Also, there should have been NO significant weaknesses identified.

(VG) Very Good Performance meets contractual requirements and exceeds some to the Government’s/Owner’s benefit.

The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

A Very Good rating is appropriate when the Contractor successfully performed a significant event that was a benefit to the Government/Owner. There should have been no significant weaknesses identified.

(S) Satisfactory Performance meets minimum contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

A Satisfactory rating is appropriate when there were only minor problems, or major problems that the contractor recovered from without impact to the contract. There should have been NO significant weaknesses identified. Per DOD policy, a fundamental principle of assigning ratings is that contractors will not be assessed a rating lower than Satisfactory solely for not performing beyond the requirements of the contract.

(M) Marginal Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor's proposed actions appear only marginally effective or were not fully implemented.

A Marginal is appropriate when a significant event occurred that the contractor had trouble overcoming which impacted the Government/Owner.

(U) Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains serious problem(s) for which the contractor's corrective actions appear or…