JSC_Form_288.doc

Statistical Information – Contractor Safety and Health Program This form is due in the Mishaps Safety Office before the Close of Business on the 10th of each calendar month.

Information and instructions are provided Submittal must be made to JSC-Safety-Report-Submittals (Global List) or JSC-Safety-Report-Submittals@mail.nasa.gov via mouse over of text or on pages 5 & 6

Section I. Basic Information.

Month / Year - to - Month / Year:

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FORMCHECKBOX

* Check if this is a revision to a previously submitted report.

Section II. Contract Team Information.

(Contractor or Sub-Contractor)

Worked This Month

Total

Section III. Loss Data.

Occupational

Injuries / Illnesses

Section III. Loss Data (continued).

Section IV. Mishap Case Updates.

File Number

NASA

USE ONLY

Date of

Event First & Last Name of Injured Employee (If applicable) Brief Description of event

CHECK (X)

CASE STATUS

New = N Continuing = CO Change = CH

CHECK (X)

ONLY ONE PER LINE

FA = first aid; ILL = Illness; MT = medical treatment; RWD = Restricted; DA = Days Away; DAM = Damage Number of

RESTRICTED

WORK DAYS

Number of

DAYS

AWAY

COST

OF

DAMAGE

Enter single $ amount for all items

(to date)

NEW

(this month) Previous (to date)

NEW

(this month)

Estimate

Final

Section V. Management Commitment and Employee Involvement. Identify the month’s events that supported Safety and Health Program Implementation. Such events typically have both management and employee involvement. Examples include safety and health meetings, safety and health days, special committees or working groups.

Section VI. Worksite Analysis. Identify the percentage of worksite analyses (audits/inspections) completed for the current month and quarter. Refer to JPR 1700.1 for definitions of terms.

Worksite Analysis Notes2:

1Worksite Analysis (Audits/Inspections) shall be conducted monthly with 100% of the worksite inspected by the end of each quarter.

2Provide explanation in the notes if inspection coverage is less than 100% for the quarter. Provide comments in the notes as needed to highlight or clarify items such as: additional or focused inspections; industrial hygiene sampling; annual program audits (such as lockout/tagout, PPE, etc.) completed.

Section VII. Hazard Prevention and Control. List below any hazards that were discovered or found to be inadequately controlled during routine and special inspections, close calls, mishap investigations, etc., and require correction. Include interim abatement if final abatement cannot be readily accomplished to protect employees and assets. Complex corrective action (abatement) plans may be attached. Hazards not finally abated within 30 days must be reported to JSC Safety for inclusion in HATS/SRTS.

if open > 30 days

Hazard Abatement Notes3:

3Include discussion of any issues associated with correcting hazards in a timely manner.

Section VIII. Safety and Health Training. List training opportunities. List expected size of target training population and percent trained at end of month. The core training opportunities should be found in the contract safety and health plan.

Safety and Health Training Notes4:

4Include any new or modified training requirements and accompanying rationale (new requirements, etc.) arising from new requirements or mandated by investigations or audits. Indicate if new requirements have been included in contractual safety and health plan.

Section IX. Significant Safety Activities and Accomplishments this past month. List any significant safety activities and accomplishments noted this past month. Examples include safety and health program milestones such as VPP certification/recertification, trend analyses with accompanying recommendations, lessons learned used from other corporate resources, etc.

Instructions for Completing JSC Form 288 NASA follows OSHA record keeping guideline:

“1904 - Recording and Reporting Occupational Injuries and Illness” - on-line link:

http://www.osha.gov/pls/oshaweb/owastand.display_standard_group?p_toc_level=1&p_part_number=1904 NAICS Codes – on line link: http://www.census.gov/eos/www/naics/ Other resources:

NPR 8715.3, NASA General Safety Program Requirements – on line link: http://www.hq.nasa.gov/office/codeq/doctree/87153.htm JPR 1700.1, “JSC Safety And Total Health Handbook” - on-line link: http://jschandbook.jsc.nasa.gov/

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SECTION I. BASIC INFORMATION.

Month / Year being Reported – the calendar month and year being reported.

Contract Reporting Period (Month / Year - to - Month / Year) – the first and last calendar month and year of the contractual reporting period in which this monthly report falls. Initially, this is the same as the first year of your contract.

Prime Contractor Name – the official full name of the prime contractor for the contract being reported.

Date Report was Prepared – self explanatory. May be different from date report was due to the Government.

Supported Directorate – the JSC directorate that is the primary customer for the work done on this contract.

Prime Contractor Phone – the phone number of the person who prepared this report.

Prime Contract Number – the official NASA contract number assigned to the contract.

Prepared By – the name and email address of the person who prepared the report.

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SECTION II. CONTRACT TEAM INFORMATION.

General Information (Name of Prime and Sub-Contractor (1, 2, etc.) – The name of the prime contractor was already entered in Section 1 and is blacked out in this section as unneeded. Each subcontractor shall be listed. List all subcontractors with annual subcontract value of $1,000,000 or more for contract year or contribute 20% or more of the direct labor hours on the contract. For subcontracts with annual value less than $1M and which contribute less than 20% of the direct labor hours of this contract need not be listed.

NAICS Code - The Industry Group number (according to the North American Industrial Classification System which best describes the work done by the listed prime and subcontractor. This may vary between the prime and subcontractors. Further information can be found at: http://www.census.gov/eos/www/naics/ Direct Labor Hours Worked This Month – for the prime and each sub contractor. Enter hours worked by all unlisted contractors in next to last line and include in total.

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SECTION III. LOSS DATA.

Note on Layout and Format: Each required data point is recorded under each month and retained on the form each month to the end of the calendar year. Each item is recorded on separate rows for onsite and offsite. Format for colunts will be in units. Format for cost will be in dollars (no decimals).

Occupational Injuries/Illnesses - To include data from all team members when incurred while doing contract work (not just that from the contractors listed in Section Ii, Contract Team Information.)

Basic requirement - Excerpt taken from § 1904.7(a)

You must consider an injury or illness to meet the general recording criteria, and therefore to be Recordable, if it results in any of the following: death, days away from work, restricted work or transfer to another job, medical treatment beyond first aid, or loss of consciousness. You must also consider a case to meet the general recording criteria if it involves a significant injury or illness diagnosed by a physician or other licensed health care professional, even if it does not result in death, days away from work, restricted work or job transfer, medical treatment beyond first aid, or loss of consciousness. (NOTE: NASA requires reports of first aid injuries that occur on NASA property.)

Number Of Employees - Record the number of different employees on payroll who are doing work on this contract. The Government may have required the contract to submit each month a personnel strength report; the contractor may attach a copy of its personnel strength report instead of completing this line.

Man-hours Worked - Record the total direct labor hours worked on NASA property (e.g., onsite) and non-NASA property (e.g., offsite). The contractor may NOT attach a copy of its JSC Form 533 instead of completing this line; this information is used by NASA to calculate INCIDENCE RATES.

Days Away, Restriction, Medical Treatment, and First Aid Cases; Injury versus Illness – NASA uses the OSHA definitions defined in 29 CFR 1904.7 and 29 CFR 1960.2. Mouse over each line for a definition of the term.

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SECTION III. (continued)

Damage Data. (Damage Incurred by) - Will include count and cost of losses (including repair) for each month while doing contract work. They may or may not have been charged off as contract cost. Each damage event will be counted regardless of the number of items damaged.

Vehicle Mishap - using any vehicle on business and intended for routine transportation

Fire Mishap - self-explanatory. Does not include explosions except as the direct result of a fire.

Property (other than vehicle or fire) – includes facilities and equipment.

Does not include personal equipment or property unless loss is covered by contractor through reimbursement or insurance

Natural PhenomenON (“Acts of God”) - self-explanatory

Other Data Close Calls Reported – Close calls as defined by JPR 1700.1 chapter 2.7, “Employee Reports of Hazards” and which were not submitted to NASA. This includes all such reports while doing contract work and handled internally by the contractor as specified in the contractual safety and health plan.

No. OSHA Inspections (by OSHA) - These may be focused inspections, compliance inspections, visits in response to an injury or complaint, etc. Indicate date and purpose of inspection in status block at bottom of form 288 and forward a copy of OSHA findings to the Safety and Test Operations Division / NS2 - Occupational Safety Team Office, by attachment to this report, or a future issue of this report, or by separate letter.

No. EPA Inspections (by the U.S. EPA or its agents including regional or state agencies) - Indicate date and purpose of inspection in status block at bottom of form 288 and forward a copy of EPA findings to the Safety and Test Operations Division / NS2 - Occupational Safety Team Office, by attachment to this report, or a future issue of this report, or by separate letter.

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SECTION IV. Mishap Case Updates This section allows contractors to provide the status of new and ongoing mishaps. The data required is self explanatory.

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SECTION V. Management Commitment and Employee Involvement.

Event or Activity – Identify the event or activity by title.

Purpose or Benefit – What was the reason for the event and what benefit can be derived from participating.

Number of managers participating – includes first-line supervisors but not group leads or staff.

Number of employees participating – includes all employees other than managers or supervisors.

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Section VI. Worksite Analysis

Instructions provided with block on form.

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Section VII. Hazard Prevention and Control

Instructions provided with block on form.

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Section VIII. Safety and Health Training.

Instructions provided with block on form.

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Section IX. Significant Safety Activities and Accomplishments this Past Month.

Instructions provided with block on form.

JSC Form 288 (Revised August 24, 2011)(MS Word November 2006)