A.02.01 Attachment 1- Specifications.pdf
PDF 5 MB Posted
- Attached to
- Exciter Supply, Norfork Powerhouse Federal contract opportunity
- Solicitation number
- W9127S20Q0002
About this file
This solicitation requests quotations for two complete digital static excitation systems and associated components for the Norfork powerhouse. The requirements include excitation systems, potential transformers, spare parts, system testing, training, and commissioning. The solicitation is unrestricted and issued by the US Army Corps of Engineers Engineering District in Little Rock under solicitation number W9127S20Q0002. Quotes are due by the specified date.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| A.07.24 Amendment 0002- Exciter Supply, NFPH.pdf | ||
| A.07.24 Amendment 0001- Exciter Supply, Norfork Powerhouse.pdf | ||
| A.02.01 Attachment A- Form PPQ-0.pdf | ||
| A.02.01 Combined Synopsis & Solicitation.pdf | ||
| A.02.01 Attachment 2- Reference Plans.pdf | ||
| A.02.01 Attachment 3- Plans.pdf |
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Text version
Attachment 1
US Army Corps of Engineers
Little Rock District SPECIFICATIONS
EXCITER SUPPLY
NORFORK POWERHOUSE
WHITE RIVER BASIN
BAXTER COUNTY, ARKANSAS
PN401258
NOVEMBER 2019
SOLICITATION NO. W9127S20Q0002
PROJECT TABLE OF CONTENTS
DIVISION 01 - GENERAL REQUIREMENTS
01 00 50 FORMS AND ATTACHMENTS
01 11 00.00 26 SUMMARY OF WORK
01 14 00.00 46 WORK RESTRICTIONS (SWL)
01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS
01 22 00.00 10 PRICE AND PAYMENT PROCEDURES
01 33 00 SUBMITTAL PROCEDURES
01 35 70 CYBERSECURITY
01 42 00 SOURCES FOR REFERENCE PUBLICATIONS
01 45 00.15 10 RESIDENT MANAGEMENT SYSTEM CONTRACTOR MODE(RMS CM)
01 78 00 CLOSEOUT SUBMITTALS
01 78 23 OPERATION AND MAINTENANCE DATA
DIVISION 13 - SPECIAL CONSTRUCTION
13 48 00.00 26 SEISMIC RESTRAINT FOR ELECTRICAL EQUIPMENT
DIVISION 26 - ELECTRICAL
26 05 00.00 26 GENERAL ELECTRICAL WORK
26 05 26.00 26 GROUNDING
26 25 00.00 26 BUS STRUCTURES
DIVISION 48 - ELECTRICAL POWER GENERATION
48 19 26.00 26 DIGITAL EXCITERS
-- End of Project Table of Contents --
PROJECT TABLE OF CONTENTS Page 1
PN401258
EXCUTERS SUPPLY
NORFORK LAKE, DAM, & POWERPLANT
BAXTER COUNTY, ARKANSAS SOLICITATION NO. W9127S20Q0002
THIS PAGE INTENTIONALLY LEFT BLANK
PN401258
EXCUTERS SUPPLY
SECTION 01 00 50
FORMS AND ATTACHMENTS
PART 1 GENERAL
Listed below, and attached at the end of this section, are forms and attachments referred to in to other parts of the technical specifications.
1.1 SUBMITTAL REGISTER
See Section 01 33 00 SUBMITTAL PROCEDURES
1.2 TRANSMITTAL FORM (ENG FORM 4025-R)
See Section 01 33 00 SUBMITTAL PROCEDURES
1.3 ACTIVITY HAZARD ANALYSIS (AHA)
See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS
1.4 ACCIDENT INVESTIGATION REPORT (ENG FORM 3394)
See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS
1.5 SWL FORM 463
See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS
1.6 OSHA FORM 300 & 301
See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS
1.7 RMS-QCS MONTHLY INJURIES-ILLNESSES & EXPOSURE
See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS
1.8 SAFETY PERFORMANCE SIGN
See Section 01 14 00.00 46 WORK RESTRICTIONS
1.9 PROJECT IDENTIFICATION SIGN
See Section 01 14 00.00 46 WORK RESTRICTIONS
1.10 USACE-LITTLE ROCK DISTRICT NATIONAL BACKGROUND SCREENING
CONSENT/RELEASE FORM (SSCI-2013)
See Section 01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS
1.11 OPTIONAL FORM 306
See Section 01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS
1.12 SWL Form 487 USACE-SWL CONTRACTOR REQUIRED INFORMATION FORM
See Section 01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS
SECTION 01 00 50 Page 1
PN401258
EXCUTERS SUPPLY
PART 2 PRODUCTS
Not Used.
PART 3 EXECUTION
Not Used
-- End of Section --
SECTION 01 00 50 Page 2
PN401258
EXCUTERS SUPPLY
SECTION 01 11 00.00 26
SUMMARY OF WORK
PART 1 GENERAL
1.1 DESCRIPTION OF WORK
The scope of work for this contract consists of the Contractor furnishing all supervision, engineering, labor, materials, and equipment to perform the following work in strict accordance with the detailed requirements of this contract:
a. Design, prepare drawings and data, manufacture, shop test, prepare and load for shipment, and deliver f.o.b. destination two complete digital static excitation systems, including power potential transformers (PPTs) and all required spare parts, for the Norfork powerhouse.
b. Perform special factory testing on digital static exciters and PPTs as specified in 48 19 26.00 26.
c. Furnish all necessary wire, cable, and buswork necessary for connection between components of the excitation systems (namely, the PPTs and exciter cabinets).
d. Perform final inspection of excitation systems, including PPTs and spare parts, prior to Government acceptance.
e. Provisioning for and performing commissioning and training activities at a later date following installation.
The scope for this contract does not include the following items:
a. Removal of the existing excitation systems.
b. Furnishing wire, cable, or buswork to be installed between the excitation system equipment and other powerhouse equipment.
c. Installation of the furnished excitation systems.
1.2 SPECIFICATIONS
Technical specifications listed below cover the detailed requirements for the equipment and services listed in the Price Schedule:
SECTION TITLE
13 48 00.00 SEISMIC RESTRAINT FOR ELECTRICAL EQUIPMENT
26 05 00.00 GENERAL ELECTRICAL WORK
26 05 26.00 GROUNDING
26 25 00.00 BUS STRUCTURES
48 19 26.00 DIGITAL EXCITERS
SECTION 01 11 00.00 26 Page 1
PN401258
EXCUTERS SUPPLY
PART 2 PRODUCTS - NOT USED
PART 3 EXECUTION - NOT USED
-- End of Section --
SECTION 01 11 00.00 26 Page 2
PN401258
EXCUTERS SUPPLY
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I ce rt if y th at t he a bo ve s ub m it te d it em s ha ve b ee n re vi ew ed in d et ai l a nd a re c or re ct a nd in s tr ic t co nf or m an ce w it h th e co nt ra ct d ra w in gs a nd s pe ci fi ca ti on s ex ce pt a s ot he r w is e st at ed
C H
EC
K O
N E:
T H
IS
I S A
N
EW
T R A
N S M
IT
T A
L T H
IS
I S A
R
ES
U B M
IT
T A
L
R A
N S M
IT
T A
L
D A
T E
R
EM
A R K S
C O
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C T R
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ER
EN
C
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O C
U M
EN
T
S
PE
C
IF
IC
A
T
IO
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EC
N
O
(C ov er o nl y on e se ct io n w it h ea ch t ra ns m it ta l)
T O
FR
O M
PR
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C
T T
IT
LE
A N
D L
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A T
IO
N
C O
N T R A
C T N
O
EN
C
LO
S U
R
ES
R
ET
U R N
ED
Li st b y It em
N o.
T R A
N S M
IT
T A
L O
F S H
O P
D R A
W
IN
G S
EQ
U
IP
M
EN
T D
A T A
M
A T
ER
IA
L
S A
M
PL
ES
O
R M
A N
U
FA
C T U
R
ER
'S C
ER
T
IF
IC
A
T
ES
O F
C O
M
PL
IA
N
C E
(R ea d in st ru ct io ns o n th e re ve rs e si de p rio r to in it ia ti ng t hi s fo rm
S
EC
T
IO
N I R
EQ
U
ES
T F
O R A
PP
R O
V A
L O
F T H
E
FO
LL
O
W
IN
G
IT
EM
S (T hi s se ct io n w ill b e in it ia te d by t he c on tr ac to r)
T R A
N S M
IT
T A
L N
N A
M E, T
IT
LE
A
N D
S
IG
N A
T U
R E
O F
A
PP
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V
IN
G A
U T H
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IT
Y D
A T E
S
EC
T
IO
N I I A
PP
R O
V A
L A
C T
IO
N
IT
EM
N O a.
D
ES
C R
IP
T
IO
N O
F
IT
EM
S
U B M
IT
T
ED
(T yp e si ze m od el n um be r/ et c.
b.
M
FG
O R C
O N
T R
C A
T
C U
R V
E D
R A
W
IN
G O
R B R O
C H
U R E
N O
(S ee in st ru ct io n no c.
N O
O
F C
O
PI
ES
d.
S
PE
C
PA
R A
N
O e.
D R A
W
IN
G S H
EE
T N
O f.
FO
C
N T R A
C T O
R U
S E
C O
D E g.
V A
R
IA
T
IO
N (S ee in st ru ct io n N o.
h.
FO
R
C E
U S E
C O
D E i.
N A
M E
A N
D S
IG
N
A T U
R E
O F
C O
N T R A
C T O
R
EN
G
F O
R M
-R
M
A R
(P ro po ne nt
C
EM
P-
C E)
ED
IT
IO
N
O F
S
EP
I S O
B S O
LE
T E.
(E R
-1
-1
C H
EC
K
O N
E:
T
H
IS
T R A
N S M
IT
T A
L
IS
FO
IO
G
V 'T
A
PP
R O
V
L
IN
T R U
C T
IO
N S
S ec ti on
I w ill b e in it ia te d by t he C on tr ac to r in t he r eq ui re d nu m be r of c op ie s.
Ea ch t ra ns m it ta l s ha ll be n um be re d co ns ec ut iv el y in t he s pa ce p ro vi de d fo r "T ra ns m it ta l N o.
T hi s nu m be r, in a dd it io n to t he c on tr ac t nu m be r, w ill f or m a s er ia l nu m be r fo r id en ti fy in g ea ch s ub m it ta l.
F or n ew s ub m it ta ls o r re su bm it ta ls m ar k th e ap pr op ria te b ox on r es ub m it ta ls in se rt t ra ns m it ta l n um be r of la st s ub m is si on a s w el l a s th e ne w s ub m it ta l n um be r.
T he
It em
N o.
w ill b e th e sa m e
"I te m N o.
as in di ca te d on E
N G
F O
R M
-R f or e ac h en tr y on t hi s fo rm
S ub m it ta ls r eq ui rin g ex pe di ti ou s ha nd lin g w ill b e su bm it te d on a s ep ar at e fo rm
S ep ar at e tr an sm it ta l f or m w ill b e us ed f or s ub m it ta ls u nd er s ep ar at e se ct io ns o f th e sp ec if ic at io ns
A c he ck s ha ll be p la ce d in t he
V ar ia ti on co lu m n w he n a su bm it ta l i s no t in a cc or da nc e w it h th e pl an s an d sp ec if ic at io ns al so a w rit te n st at em en t to t ha t ef fe ct sh al l b e in cl ud ed in t he s pa ce p ro vi de d fo r "R em ar ks
Fo rm is s el f-tr an sm it ta l, le tt er o f tr an sm it ta l i s no t re qu ire d.
W he n a sa m pl e of m at er ia l o r M an uf ac tu re r' s C er ti fi ca te o f C om pl ia nc e is t ra ns m it te d, in di ca te
S am pl e" o r
"C er ti fi ca te in c ol um n c, S ec ti on
I
U .S
A rm y
C or ps o f En gi ne er s ap pr ov in g au th or it y w ill a ss ig n ac ti on c od es a s in di ca te d be lo w in s pa ce p ro vi de d in S ec ti on
I co lu m n i t o ea ch it em s ub m it te d.
In ad di ti on t he y w ill e ns ur e en cl os ur es a re in di ca te d an d at ta ch ed t o th e fo rm p rio r to r et ur n to t he c on tr ac to r.
he
C on tr ac to r w ill a ss ig n ac ti on c od es a s in di ca te d be lo w in
S ec ti on
I co lu m n g, t o ea ch it em s ub m it te
d. T H
E
FO
LL
O
W
IN
G A
C T
IO
N C
O D
ES
A
R E
G
IV
EN
T
O I T
EM
S S
U B M
IT
T
ED
A
A pp ro ve d as s ub m it te d.
B
A pp ro ve d, e xc ep t as n ot ed o n dr aw in gs
C
A pp ro ve d, e xc ep t as n ot ed o n dr aw in gs
R ef er t o at ta ch ed s he et r es ub m is si on r eq ui re d.
D
W ill b e re tu rn ed b y se pa ra te c or re sp on de nc e.
A pp ro va l o f it em s do es n ot r el ie ve t he c on tr ac to r fr om c om pl yi ng w it h al l t he r eq ui re m en ts o f th e co nt ra ct p la ns a nd s pe ci fic at io ns
(R ev er se o f
EN
G
F or m
-R
E
D is ap pr ov ed
S ee a tt ac he d)
F
R ec ei pt a ck no w le dg ed
FX
R ec ei pt a ck no w le dg ed do es n ot c om pl y as n ot ed w it h co nt ra ct r eq ui re m en ts
G
O th er
S pe ci fy
T
IV
IT
Y
H A
Z A
R D
A N
A L
Y
SI
N T
R A
C T
N O
PR
O
JE
D
E
L
C A
T
IO
N
ST
IM
A T
E D
S T
A R
T D
A
PR
C
IP
A L
S T
PS
PO
E
N T
IA
L
S A
FE
T
Y /H
E A
L T
H H
A
ZA
R D
S R
E C
O M
M E
N D
E D
C O
N T
R O
L S
Id en tif y th e pr in ci pa l s te ps in vo lv ed a nd th e se qu en ce o f w or k ac tiv iti es
An al yz e ea ch p ri nc ip al st ep fo r p ot en tia l h az ar ds ev el op sp ec ifi c co nt ro ls fo r e ac h po te nt ia l h az ar d
Q
U
IP
M E
N T
T O
B E
U
SE
SP
E C
T
IO
N R
E Q
U
IR
E M
E N
T S
T R
A
IN
IN
G
R E
Q U
IR
E
M E
N T
S Li st e qu ip m en t t o be u se d in th e w or k ac tiv ity
Li st in sp ec tio n re qu ir em en ts fo r t he w or k ac tiv ity
Li st tr ai ni ng re qu ir em en ts , i nc lu di ng h az ar d co m m un ic at io n
N T
R A
C T
O R
(S ig na tu re d at e)
5.
d. CONTRACTOR'S NAME
SIDE SWIPE
BROADSIDE
OTHER (Specify)
e. BODY PART AFFECTED
REAR END
BACKING
HEAD ON
ROLL OVER
d. ESTIMATED DAYS
RESTRICTED DUTY
b. ESTIMATED
DAYS LOST
c. ESTIMATED
DAYS HOSPIT-
ALIZED
b. TYPE OF CONSTRUCTION EQUIPMENT
SUPERFUND
IRP
b. TYPE OF COLLISION/MISHAP
a. ACTIVITY AT TIME OF ACCIDENT
g. HAZARDOUS/TOXIC WASTE
ACTIVITY
(For Safety Staff only)
REPORT NO. EROC
CODE UNITED STATES ARMY CORPS OF ENGINEERS
ACCIDENT INVESTIGATION REPORT
REQUIREMENT
CONTROL SYMBOL:
CEEC-S-8(R2)
PERSONNEL CLASSIFICATION
GOVERNMENT
INJURY/ILLNESS/FATAL PROPERTY DAMAGE MOTOR VEHICLE INVOLVED DIVING
a. Name (Last, First, MI) b. AGE c. SEX d. SOCIAL SECURITY NUMBER e. GRADE
f. JOB SERIES/TITLE g. DUTY STATUS AT TIME OF ACCIDENT h. EMPLOYMENT STATUS AT TIME OF ACCIDENT
a. DATE OF ACCIDENT (month/day/year)
b. TIME OF ACCIDENT (Military time)
e. CONTRACT NUMBER f. TYPE OF CONTRACT
c. EXACT LOCATION OF ACCIDENT
a. CONSTRUCTION ACTIVITY
a. SEVERITY OF ILLNESS/INJURY
g. TYPE AND SOURCE OF INJURY/ILLNESS
f. NATURE OF ILLNESS/INJURY
a. TYPE OF VEHICLE
a. NAME OF ITEM b. OWNERSHIP c. $ AMOUNT OF DAMAGE
(1)
(2)
(3)
a. TYPE OF VESSEL/FLOATING PLANT
b. PERSONAL FLOATATION DEVICE USED?
b. TYPE OF COLLISION c. SEAT BELTS USED NOT USED NOT AVAILABLE
(1) FRONT SEAT
(2) REAR SEAT
10. ACCIDENT DESCRIPTION (Use additional paper, if necessary)
8. PROPERTY/MATERIAL INVOLVED
9. VESSEL/FLOATING PLANT ACCIDENT (Fill in line and correspondence code number in box from list - see help menu)
7. MOTOR VEHICLE ACCIDENT
INJURY/ILLNESS INFORMATION (Include name on line and corresponding code number in box for items e, f & g - see help menu)
4. CONSTRUCTION ACTIVITIES ONLY (Fill in line and corresponding code number in box from list - see help menu)
3. GENERAL INFORMATION
2. PERSONAL DATA
1. ACCIDENT CLASSIFICATION
6. PUBLIC FATALITY (Fill in line and correspondence code number in box - see help menu)
CIVILIAN MILITARY
CONTRACTOR
FIRE
INVOLVED OTHER
FIRE
INVOLVED OTHER
OTHERFATAL
MALE FEMALE
ON DUTY
OFF DUTY
TDY
ARMY ACTIVE
PERMANENT
TEMPORARY
OTHER (Specify)
ARMY RESERVE
FOREIGN NATIONAL
STUDENT
VOLUNTEER
SEASONAL
CONSTRUCTION
A/E
OTHER (Specify)
SERVICE
DREDGE
DERP
OTHER (Specify)
(1) PRIME:
(2) SUBCONTRACTOR:
(CODE) (CODE)
(CODE)
(CODE)
(CODE)
(CODE)
(CODE)
(CODE)
(CODE) (CODE)
(CODE)
CIVIL WORKS
OTHER (Specify)
MILITARY
PRIMARY
SECONDARY TYPE
SOURCE
YES N/ANO
AUTOMOBILE
OTHER (Specify)
PICKUP/VAN
TRUCK
ENG FORM 3394, MAR 99 EDITION OF SEP 89 IS OBSOLETE. Page 1 of 4 pages (Proponent: CESO ) hrs
(For Use of this Form See Help Menu and USACE Suppl to AR 385-40)
PUBLIC
Version 2 a.
a.
a.
b. TYPE OF TRAINING. a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK?
b. WAS A WRITTEN JOB/ACTIVITY HAZARD ANALYSIS COMPLETED
FOR TASK BEING PERFORMED AT TIME OF ACCIDENT?
a. (CONTINUED) a. (Explain YES answers in item 13)
CAUSAL FACTOR(S) (Read Instruction Before Completing)11.
TRAINING12.
FULLY EXPLAIN WHAT ALLOWED OR CAUSED THE ACCIDENT; INCLUDE DIRECT AND INDIRECT CAUSES (See instruction for definition of direct and indirect causes.) (Use additional paper, if necessary)
13.
ACTION(S) TAKEN, ANTICIPATED OR RECOMMENDED TO ELIMINATE CAUSE(S).14.
DATES FOR ACTIONS IDENTIFIED IN BLOCK 14.15.
MANAGEMENT REVIEW (1st)16.
MANAGEMENT REVIEW (2nd - Chief Operations, Construction, Engineering, etc.)17.
SAFETY AND OCCUPATIONAL HEALTH OFFICE REVIEW18.
COMMAND APPROVAL19.
c. DATE OF MOST RECENT FORMAL TRAINING.
a. DIRECT CAUSE
b. INDIRECT CAUSE(S)
DESCRIBE FULLY:
c. SIGNATURE AND TITLE OF SUPERVISOR COMPLETING REPORT
CORPS
CONTRACTOR
d. DATE (Mo/Da/Yr) e. ORGANIZATION IDENTIFIER (Div, Br, Sect) f. OFFICE SYMBOL
SIGNATURE TITLE DATE
COMMENTS
DATE
DATE
DATECOMMANDER SIGNATURE
TITLE
TITLE
SIGNATURE
SIGNATURE
a. BEGINNING (Month/Day/Year) b. ANTICIPATED COMPLETION (Month/Day/Year)
DESIGN: Was design of facility, workplace or equipment a factor?
INSPECTION/MAINTENANCE: Were inspection & mainten-ance procedures a factor?
PERSON'S PHYSICAL CONDITION: In your opinion, was the physical condition of the person a factor?
OPERATING PROCEDURES: Were operating procedures a factor?
JOB PRACTICES: Were any job safety/health practices not followed when the accident occurred?
HUMAN FACTORS: Did any human factors such as, size or strength of person, etc., contribute to accident?
ENVIRONMENTAL FACTORS: Did heat, cold, dust, sun, glare, etc., contribute to the accident?
OFFICE FACTORS: Did office setting such as, lifting office furniture, carrying, stooping, etc., contribute to the accident?
SUPPORT FACTORS: Were inappropriate tools/resources provided to properly perform the activity/task?
PERSONAL PROTECTIVE EQUIPMENT: Did the improper selection, use or maintenance of personal protective equipment contribute to the accident?
DRUGS/ALCOHOL: In your opinion, was drugs or alcohol a factor to the accident
CHEMICAL AND PHYSICAL AGENT FACTORS: Did exposure to chemical agents, such as dust, fumes, mists, vapors or physical agents, such as, noise, radiation, etc., contribute to accident?
CONCUR b. NON CONCUR c. COMMENTS
CONCUR b. NON CONCUR c. COMMENTS
CONCUR b. NON CONCUR c. ADDITIONAL ACTIONS/COMMENTS
Page 2 of 4 pages
YES (If yes, attach a copy.) NO
NOYES ON JOBCLASSROOM (Month) (Day) (Year)
YES NO YES NO
*U.S. GOVERNMENT PRINTING OFFICE: 1993-0-791-757
ACCIDENT DESCRIPTION (Continuation)
DIRECT CAUSE (Continuation)
10.
13a.
Page 3 of 4 pages
INDIRECT CAUSES (Continuation)
ACTION(S) TAKEN, ANTICIPATED, OR RECOMMENDED TO ELIMINATE CAUSE(S) (Continuation)
13b.
14.
Page 4 of 4 pages
H A
F o rm s fo r
R e c o rd in g W o rk
-R e la te d I n ju ri e s a n d
I ll n e ss e s
W h a t’ s
In si d e
In th is p ac k ag e, yo u ’l l fi n d ev er yt h in g yo u n ee d to co m p le te
O S
H A
’s an d th e fo r th e n e x t se ve ra l ye ar s.
O n th e fo ll o w in g p ag es yo u ’l l fi n d
G en er al in st ru ct io n s fo r fi ll in g o u t th e fo rm s in th is p ac k ag e an d d ef in it io n s o f te rm s yo u sh o u ld u se w h en yo u cl as si fy yo u r ca se s as in ju ri es o r il ln es se s.
A n e x am p le to g u id e yo u in fi ll in g o u t th e p ro p er ly
S ev er al p ag es o f th e
(b u t yo u m ay m ak e as m an y co p ie s o f th e as yo u n ee d
N o ti ce th at th e is se p ar at e fr o m th e
R em o va b le p ag es fo r ea sy p o st in g at th e en d o f th e ye ar
N o te th at yo u p o st th e o n ly n o t th e
A w o rk sh ee t fo r fi g u ri n g th e av er ag e n u m b er o f em p lo ye es w h o w o rk ed fo r yo u r es ta b li sh m en t an d th e to ta l n u m b er o f h o u rs w o rk ed
A co p y o f th e
O S
H A to p ro vi d e d et ai ls ab o u t th e in ci d en t.
Y o u m ay m ak e as m an y co p ie s as yo u n ee d o r u se an eq u iv al en t fo rm
T ak e a fe w m in u te s to re vi ew th is p ac k ag e.
If yo u h av e an y q u es ti o n s, W e’ ll b e h ap p y to h el p yo u
L og
S u m m ar y of W or k-
R el at ed
In ju ri es an d
Il ln es se s
L og
L og
L og
L og
S u m m ar y.
S u m m ar y
S u m m ar y
L og
A n
O ve rv ie w
R e c o rd in g W o rk
-R e la te d I n ju ri e s a n d
I ll n e ss e s
H o w t o F il l
O u t th e L o g
L o g o f W o rk
-R e la te d I n ju ri e s a n d
Il ln e ss e s
S u m m a ry o f
W o rk -R e la te d
I n ju ri e s a n d Il ln e ss e s
W o rk sh e e t to
H e lp Y o u
F il l O u t th e
S u m m a ry
O S
H A
’s
In ju ry a n d I ll n e ss
I n c id e n t R e p o rt o r vi si t u s o n li n e a t w w w
.o sh a g o v c a ll y o u r lo c a l O
S H
A o ff ic e
U.S. Department of Labor Occupational Safety and Health Administration
D e a r
E m p lo ye r:
T h is b o o k le t in cl u d es th e fo rm s n ee d ed fo r m ai n ta in in g o cc u p at io n al in ju ry an d il ln es s re co rd s fo r
T h es e n ew fo rm s h av e ch an g ed in se ve ra l im p o rt an t w ay s fr o m th e re co rd k ee p in g fo rm s.
In th e
O S
H A an n o u n ce d it s d ec is io n to ad d an o cc u p at io n al h ea ri n g lo ss co lu m n to
O S
H A
’s F o rm
L o g o f
W o rk -R el at ed In ju ri es an d Il ln es se s.
T h is fo rm s p ac k ag e co n ta in s m o d if ie d
F o rm s an d
A w h ic h in co rp o ra te th e ad d it io n al co lu m n M
(5
H ea ri n g L o ss
E m p lo ye rs re q u ir ed to co m p le te th e in ju ry an d il ln es s fo rm s m u st b eg in to u se th es e fo rm s o n
Ja n u ar y
In re sp o n se to p u b li c su g g es ti o n s, O
S H
A al so h as m ad e se ve ra l ch an g es to th e fo rm s p ac k ag e to m ak e th e re co rd k ee p in g m at er ia ls cl ea re r an d ea si er to u se
O n F o rm w e’ ve sw it ch ed th e p o si ti o n s o f th e d ay co u n t co lu m n s.
T h e d ay s
“a w ay fr o m w o rk co lu m n n o w co m es b ef o re th e d ay s “o n jo b tr an sf er o r re st ri ct io n
W e’ ve cl ar if ie d th e fo rm u la s fo r ca lc u la ti n g in ci d en ce ra te s.
W e’ ve ad d ed n ew re co rd in g cr it er ia fo r o cc u p at io n al h ea ri n g lo ss to th e
“O ve rv ie w se ct io n
O n F o rm w e’ ve m ad e th e co lu m n h ea d in g
“C la ss if y th e C as e” m o re p ro m in en t to m ak e it cl ea r th at em p lo ye rs sh o u ld m ar k o n ly o n e se le ct io n am o n g th e fo u r co lu m n s o ff er ed
T h e O cc u p at io n al S af et y an d H ea lt h A d m in is tr at io n sh ar es w it h yo u th e g o al o f p re ve n ti n g in ju ri es an d il ln es se s in o u r n at io n ’s w o rk p la ce s.
A cc u ra te in ju ry an d il ln es s re co rd s w il l h el p u s ac h ie ve th at g o al
D ec em b er
F ed er al R eg is te r
(6
F R
-7
O cc u pa ti on al S af et y an d H ea lt h A dm in is tr at io n
U .S
D ep ar tm en t of
L ab or h e (F o rm is u se d to cl as si fy w o rk
-r el at ed in ju ri es an d il ln es se s an d to n o te th e e x te n t an d se ve ri ty o f ea ch ca se W h en an in ci d en t o cc u rs u se th e to re co rd sp ec if ic d et ai ls ab o u t w h at h ap p en ed an d h o w it h ap p en ed
T h e a se p ar at e fo rm (F o rm
A sh o w s th e to ta ls fo r th e ye ar in ea ch ca te g o ry A t th e en d o f th e ye ar p o st th e in a vi si b le lo ca ti o n so th at yo u r em p lo ye es ar e aw ar e o f th e in ju ri es an d il ln es se s o cc u rr in g in th ei r w o rk p la ce
E m p lo ye rs m u st k ee p a fo r ea ch es ta b li sh m en t o r si te
If yo u h av e m o re th an o n e es ta b li sh m en t, yo u m u st k ee p a se p ar at e an d fo r ea ch p h ys ic al lo ca ti o n th at is e x p ec te d to b e in o p er at io n fo r o n e ye ar o r lo n g er
N o te th at yo u r em p lo ye es h av e th e ri g h t to re vi ew yo u r in ju ry an d il ln es s re co rd s.
F o r m o re in fo rm at io n se e
C o d e o f F ed er al R eg u la ti o n s P ar t
.3
C as es li st ed o n th e ar e n o t n ec es sa ri ly el ig ib le fo r w o rk er s’ co m p en sa ti o n o r o th er in su ra n ce b en ef it s.
L is ti n g a ca se o n th e d o es n o t m ea n th at th e em p lo ye r o r w o rk er w as at fa u lt o r th at an
O S
H A st an d ar d w as vi o la te d
R ec o rd th o se w o rk
-r el at ed in ju ri es an d il ln es se s th at re su lt in d ea th lo ss o f co n sc io u sn es s, d ay s aw ay fr o m w o rk re st ri ct ed w o rk ac ti vi ty o r jo b tr an sf er o r m ed ic al tr ea tm en t b ey o n d fi rs t ai d
Y o u m u st al so re co rd w o rk
-r el at ed in ju ri es an d il ln es se s th at ar e si g n if ic an t
(a s d ef in ed b el o w o r m ee t an y o f th e ad d it io n al cr it er ia li st ed b el o w
L og of W or k-
R el at ed
In ju ri es an d
Il ln es se s
L og
S u m m ar y
S u m m ar y
L og
L og
S u m m ar y
E m pl oy ee In vo lv em en t.
L og of W or k-
R el at ed
In ju ri es an d
Il ln es se s
L og
W h e n i s a n i n ju ry o r il ln e ss c o n si d e re d w o rk -r e la te d
W h ic h w o rk -r e la te d i n ju ri e s a n d il ln e ss e s sh o u ld y o u r e c o rd
A n in ju ry o r il ln es s is co n si d er ed w o rk -r el at ed if an ev en t o r e x p o su re in th e w o rk en vi ro n m en t ca u se d o r co n tr ib u te d to th e co n d it io n o r si g n if ic an tl y ag g ra va te d a p re e x is ti n g co n d it io n
W o rk
-r el at ed n es s is p re su m ed fo r in ju ri es an d il ln es se s re su lt in g fr o m ev en ts o r e x p o su re s o cc u rr in g in th e w o rk p la ce u n le ss an e x ce p ti o n sp ec if ic al ly ap p li es
S ee
C
F R
P ar t
.5
(b fo r th e e x ce p ti o n s.
T h e w o rk en vi ro n m en t in cl u d es th e es ta b li sh m en t an d o th er lo ca ti o n s w h er e o n e o r m o re em p lo ye es ar e w o rk in g o r ar e p re se n t as a co n d it io n o f th ei r em p lo ym en t.
S ee
C F
R P ar t
.5 (b
Y o u m u st re co rd an y si g n if ic an t w o rk re la te d in ju ry o r il ln es s th at is d ia g n o se d b y a p h ys ic ia n o r o th er li ce n se d h ea lt h ca re p ro fe ss io n al Y o u m u st re co rd an y w o rk -r el at ed ca se in vo lv in g ca n ce r, ch ro n ic ir re ve rs ib le d is ea se a fr ac tu re d o r cr ac k ed b o n e, o r a p u n ct u re d ea rd ru m S ee
C
F R
.7
Y o u m u st re co rd th e fo ll o w in g co n d it io n s w h en th ey ar e w o rk
-r el at ed an y n ee d le st ic k in ju ry o r cu t fr o m a sh ar p o b je ct th at is co n ta m in at ed w it h an o th er p er so n
’s b lo o d o r o th er p o te n ti al ly in fe ct io u s m at er ia l;
an y ca se re q u ir in g an em p lo ye e to b e m ed ic al ly re m o ve d u n d er th e re q u ir em en ts o f an
O S
H A h ea lt h st an d ar d tu b er cu lo si s in fe ct io n as ev id en ce d b y a p o si ti ve sk in te st o r d ia g n o si s b y a p h ys ic ia n o r o th er li ce n se d h ea lt h ca re p ro fe ss io n al af te r e x p o su re to a k n o w n ca se o f ac ti ve tu b er cu lo si s.
an em p lo ye e' s h ea ri n g te st
(a u d io g ra m re ve al s th at th e em p lo ye e h as e x p er ie n ce d a S ta n d ar d T h re sh o ld S h if t (S
T S in h ea ri n g in o n e o r b o th ea rs (a ve ra g ed at an d
H
z) an d th e em p lo ye e' s to ta l h ea ri n g le ve l is d ec ib el s
(d B o r m o re ab o ve au d io m et ri c ze ro al so av er ag ed at an d
H
z) in th e sa m e ea r( s) as th e S
T S
M ed ic al tr ea tm en t in cl u d es m an ag in g an d ca ri n g fo r a p at ie n t fo r th e p u rp o se o f co m b at in g d is ea se o r d is o rd er T h e fo ll o w in g ar e n o t co n si d er ed m ed ic al tr ea tm en ts an d ar e
N O
T re co rd ab le vi si ts to a d o ct o r o r h ea lt h ca re p ro fe ss io n al so le ly fo r o b se rv at io n o r co u n se li n g
W h a t a re t h e a d d it io n a l c ri te ri a
W h a t is m e d ic a l tr e a tm e n t?
A n
O ve rv ie w
R e c o rd in g W o rk
-R e la te d I n ju ri e s a n d
I ll n e ss e s
W h a t d o y o u n e e d t o d o
W it h in ca le n d ar d ay s af te r yo u re ce iv e in fo rm at io n ab o u t a ca se d ec id e if th e ca se is re co rd ab le u n d er th e O
S H
A re co rd k ee p in g re q u ir em en ts
D et er m in e w h et h er th e in ci d en t is a n ew ca se o r a re cu rr en ce o f an e x is ti n g o n e.
d en ti fy th e em p lo ye e in vo lv ed u n le ss it is a p ri va cy co n ce rn ca se as d es cr ib ed b el o w d en ti fy w h en an d w h er e th e ca se o cc u rr ed
D es cr ib e th e ca se as sp ec if ic al ly as yo u ca n
Id en ti fy w h et h er th e ca se is an in ju ry o r il ln es s.
If th e ca se is an in ju ry ch ec k th e in ju ry ca te g o ry
If th e ca se is an il ln es s, ch ec k th e ap p ro p ri at e il ln es s ca te g o ry
E st ab li sh w h et h er th e ca se w as w o rk re la te d
If th e ca se is re co rd ab le d ec id e w h ic h fo rm yo u w il l fi ll o u t as th e in ju ry an d il ln es s in ci d en t re p o rt
Y o u m ay u se o r an eq u iv al en t fo rm
S o m e st at e w o rk er s co m p en sa ti o n in su ra n ce o r o th er re p o rt s m ay b e ac ce p ta b le su b st it u te s, as lo n g as th ey p ro vi d e th e sa m e in fo rm at io n as th e
O S
H A
I I C la ss if y th e se ri o u sn es s o f th e ca se b y re co rd in g th e as so ci at ed w it h th e ca se w it h co lu m n G
(D ea th b ei n g th e m o st se ri o u s an d co lu m n
J (O th er re co rd ab le ca se s) b ei n g th e le as t se ri o u s.
O S
H A
’s
In ju ry an d
Il ln es s
In ci d en t R ep or t
H o w t o w o rk w it h t h e
L o g m o st se ri o u s o u tc o m e
Th e
O cc up at io na l S af et y an d
H ea lth (O
SH
) A ct o f 1 re qu ire s ce rta in e m pl oy er s to p re pa re a nd m ai nt ai n re co rd s of w or k-re la te d in ju rie s an d ill ne ss es
. U se th es e de fin iti on s w he n yo u cl as si fy c as es o n th e
Lo g.
O
SH
A’ s re co rd ke ep in g re gu la tio n
(s ee
C
FR
P ar t 1
4) p ro vi de s m or e in fo rm at io n ab ou t t he d ef in iti on s be lo w
U.S. Department of Labor Occupational Safety and Health Administration d ia g n o st ic p ro ce d u re s, in cl u d in g ad m in is te ri n g p re sc ri p ti o n m ed ic at io n s th at ar e u se d so le ly fo r d ia g n o st ic p u rp o se s;
an d an y p ro ce d u re th at ca n b e la b el ed fi rs t ai d
Y o u m u st co n si d er th e fo ll o w in g ty p es o f in ju ri es o r il ln es se s to b e p ri va cy co n ce rn ca se s:
an in ju ry o r il ln es s to an in ti m at e b o d y p ar t o r to th e re p ro d u ct iv e sy st em an in ju ry o r il ln es s re su lt in g fr o m a se x u al as sa u lt a m en ta l il ln es s, a ca se o f H
IV
in fe ct io n h ep at it is o r tu b er cu lo si s, a n ee d le st ic k in ju ry o r cu t fr o m a sh ar p o b je ct th at is co n ta m in at ed w it h b lo o d o r o th er p o te n ti al ly in fe ct io u s m at er ia l (s ee
C F
R P ar t
.8 fo r d ef in it io n an d o th er il ln es se s, if th e em p lo ye e in d ep en d en tl y an d vo lu n ta ri ly re q u es ts th at h is o r h er n am e n o t b e en te re d o n th e lo g
Y o u m u st n o t en te r th e em p lo ye e’ s n am e o n th e
O S
H A fo r th es e ca se s.
In st ea d en te r
“p ri va cy ca se in th e sp ac e n o rm al ly u se d fo r th e em p lo ye e’ s n am e.
Y o u m u st k ee p a se p ar at e, co n fi d en ti al li st o f th e ca se n u m b er s an d em p lo ye e n am es fo r th e es ta b li sh m en t’ s p ri va cy co n ce rn ca se s so th at yo u ca n u p d at e th e ca se s an d p ro vi d e in fo rm at io n to th e g o ve rn m en t if as k ed to d o so
If yo u h av e a re as o n ab le b as is to b el ie ve th at in fo rm at io n d es cr ib in g th e p ri va cy co n ce rn ca se m ay b e p er so n al ly id en ti fi ab le ev en th o u g h th e em p lo ye e’ s n am e h as b ee n o m it te d yo u m ay u se d is cr et io n in d es cr ib in g th e in ju ry o r il ln es s o n b o th th e O
S H
A an d fo rm s.
Y o u m u st en te r en o u g h in fo rm at io n to id en ti fy th e ca u se o f th e in ci d en t an d th e g en er al se ve ri ty o f th e in ju ry o r il ln es s, b u t yo u d o n o t n ee d to in cl u d e d et ai ls o f an in ti m at e o r p ri va te n at u re co n tu si o n ch ip p ed to o th
S ee be lo w fo r m or e in fo rm at io n ab ou t fi rs t ai d.
L og
U n d e r w h a t c ir c u m st a n c e s sh o u ld y o u N
O T e n te r th e e m p lo ye e
’s n a m e o n t h e
O S
H A
F o rm
C la ss if yi n g i n ju ri e s
A n in ju ry is an y w o u n d o r d am ag e to th e b o d y re su lt in g fr o m an ev en t in th e w o rk en vi ro n m en t.
C u t, p u n ct u re la ce ra ti o n ab ra si o n fr ac tu re b ru is e, am p u ta ti o n in se ct b it e, el ec tr o cu ti o n o r a th er m al ch em ic al el ec tr ic al o r ra d ia ti o n b u rn S p ra in an d st ra in in ju ri es to m u sc le s, jo in ts an d co n n ec ti ve ti ss u es ar e cl as si fi ed as in ju ri es w h en th ey re su lt fr o m a sl ip tr ip fa ll o r o th er si m il ar ac ci d en ts
E xa m p le s:
W h a t is f ir st a id
If th e in ci d en t re q u ir ed o n ly th e fo ll o w in g ty p es o f tr ea tm en t, co n si d er it fi rs t ai d
D o N
O T re co rd th e ca se if it in vo lv es o n ly u si n g n o n -p re sc ri p ti o n m ed ic at io n s at n o n p re sc ri p ti o n st re n g th ad m in is te ri n g te ta n u s im m u n iz at io n s;
cl ea n in g fl u sh in g o r so ak in g w o u n d s o n th e sk in su rf ac e;
u si n g w o u n d co ve ri n g s, su ch as b an d ag es
B an d A id s™ g au ze p ad s, et c.
o r u si n g S te ri
S tr ip s™ o r b u tt er fl y b an d ag es u si n g h o t o r co ld th er ap y;
u si n g an y to ta ll y n o n -r ig id m ea n s o f su p p o rt su ch as el as ti c b an d ag es w ra p s, n o n
-r ig id b ac k b el ts et c.
u si n g te m p o ra ry im m o b il iz at io n d ev ic es w h il e tr an sp o rt in g an ac ci d en t vi ct im
(s p li n ts sl in g s, n ec k co ll ar s, o r b ac k b o ar d s) d ri ll in g a fi n g er n ai l o r to en ai l to re li ev e p re ss u re o r d ra in in g fl u id s fr o m b li st er s;
u si n g ey e p at ch es u si n g si m p le ir ri g at io n o r a co tt o n sw ab to re m o ve fo re ig n b o d ie s n o t em b ed d ed in o r ad h er ed to th e ey e;
u si n g ir ri g at io n tw ee ze rs co tt o n sw ab o r o th er si m p le m ea n s to re m o ve sp li n te rs o r fo re ig n m at er ia l fr o m ar ea s o th er th an th e ey e;
u si n g fi n g er g u ar d s;
u si n g m as sa g es d ri n k in g fl u id s to re li ev e h ea t st re ss
R es tr ic te d w o rk ac ti vi ty o cc u rs w h en as th e re su lt o f a w o rk -r el at ed in ju ry o r il ln es s, an em p lo ye r o r h ea lt h ca re p ro fe ss io n al k ee p s, o r re co m m en d s k ee p in g an em p lo ye e fr o m d o in g th e ro u ti n e fu n ct io n s o f h is o r h er jo b o r fr o m w o rk in g th e fu ll w o rk d ay th at th e em p lo ye e w o u ld h av e b ee n sc h ed u le d to w o rk b ef o re th e in ju ry o r il ln es s o cc u rr ed
If th e o u tc o m e o r e x te n t o f an in ju ry o r il ln es s ch an g es af te r yo u h av e re co rd ed th e ca se si m p ly d ra w a li n e th ro u g h th e o ri g in al en tr y o r, if yo u w is h d el et e o r w h it e-o u t th e o ri g in al en tr y.
T h en w ri te th e n ew en tr y w h er e it b el o n g s.
R em em b er yo u n ee d to re co rd th e m o st se ri o u s o u tc o m e fo r ea ch ca se
� � � H o w d o y o u d e c id e i f th e c a se i n vo lv e d re st ri c te d w o rk
H o w d o y o u c o u n t th e n u m b e r o f d a ys o f re st ri c te d w o rk a c ti vi ty o r th e n u m b e r o f d a ys a w a y fr o m w o rk
W h a t if t h e o u tc o m e c h a n g e s a ft e r yo u re c o rd t h e c a se
C o u n t th e n u m b er o f ca le n d ar d ay s th e em p lo ye e w as o n re st ri ct ed w o rk ac ti vi ty o r w as aw ay fr o m w o rk as a re su lt o f th e re co rd ab le in ju ry o r il ln es s.
D o n o t co u n t th e d ay o n w h ic h th e in ju ry o r il ln es s o cc u rr ed in th is n u m b er
B eg in co u n ti n g d ay s fr o m th e d ay th e in ci d en t o cc u rs If a si n g le in ju ry o r il ln es s in vo lv ed b o th d ay s aw ay fr o m w o rk an d d ay s o f re st ri ct ed w o rk ac ti vi ty en te r th e to ta l n u m b er o f d ay s fo r ea ch Y o u m ay st o p co u n ti n g d ay s o f re st ri ct ed w o rk ac ti vi ty o r d ay s aw ay fr o m w o rk o n ce th e to ta l o f ei th er o r th e co m b in at io n o f b o th re ac h es d ay s.
af te r la ss if yi n g i ll n e ss e s
S k in d is e a se s o r d is o rd e rs
R e sp ir a to ry c o n d it io n s
H e a ri n g
L o ss
A ll o th e r il ln e ss e s
S k in d is ea se s o r d is o rd er s ar e il ln es se s in vo lv in g th e w o rk er
’s sk in th at ar e ca u se d b y w o rk e x p o su re to ch em ic al s, p la n ts o r o th er su b st an ce s.
C o n ta ct d er m at it is ec ze m a, o r ra sh ca u se d b y p ri m ar y ir ri ta n ts an d se n si ti ze rs o r p o is o n o u s p la n ts o il ac n e;
fr ic ti o n b li st er s, ch ro m e u lc er s;
in fl am m at io n o f th e sk in
R es p ir at o ry co n d it io n s ar e il ln es se s as so ci at ed w it h b re at h in g h az ar d o u s b io lo g ic al ag en ts ch em ic al s, d u st g as es va p o rs o r fu m es at w o rk
S il ic o si s, as b es to si s, p n eu m o n it is p h ar yn g it is rh in it is o r ac u te co n g es ti o n fa rm er ’s lu n g b er yl li u m d is ea se tu b er cu lo si s, o cc u p at io n al as th m a, re ac ti ve ai rw ay s d ys fu n ct io n sy n d ro m e (R
A D
S ch ro n ic o b st ru ct iv e p u lm o n ar y d is ea se (C
O P
D h yp er se n si ti vi ty p n eu m o n it is to x ic in h al at io n in ju ry su ch as m et al fu m e fe ve r, ch ro n ic o b st ru ct iv e b ro n ch it is an d o th er p n eu m o co n io se s.
N o is e-in d u ce d h ea ri n g lo ss is d ef in ed fo r re co rd k ee p in g p u rp o se s as a ch an g e in h ea ri n g th re sh o ld re la ti ve to th e b as el in e au d io g ra m o f an av er ag e o f d
B o r m o re in ei th er ea r at an d h er tz
A ll o th er o cc u p at io n al il ln es se s.
H ea ts tr o k e, su n st ro k e, h ea t e x h au st io n h ea t st re ss an d o th er ef fe ct s o f en vi ro n m en ta l h ea t;
fr ee zi n g fr o st b it e, an d o th er ef fe ct s o f e x p o su re to lo w te m p er at u re s;
d ec o m p re ss io n si ck n es s;
ef fe ct s o f io n iz in g ra d ia ti o n
(i so to p es x
-r ay s, ra d iu m ef fe ct s o f n o n io n iz in g ra d ia ti o n
(w el d in g fl as h u lt ra
-v io le t ra ys la se rs an th ra x b lo o d b o rn e p at h o g en ic d is ea se s, su ch as
A
ID
S H
IV
h ep at it is
B o r h ep at it is C b ru ce ll o si s;
m al ig n an t o r
E xa m p le s:
E xa m p le s:
E xa m p le s:
P o is o n in g P o is o n in g in cl u d es d is o rd er s ev id en ce d b y ab n o rm al co n ce n tr at io n s o f to x ic su b st an ce s in b lo o d o th er ti ss u es o th er b o d il y fl u id s, o r th e b re at h th at ar e ca u se d b y th e in g es ti o n o r ab so rp ti o n o f to x ic su b st an ce s in to th e b o d y.
P o is o n in g b y le ad m er cu ry ca d m iu m ar se n ic o r o th er m et al s;
p o is o n in g b y ca rb o n m o n o x id e, h yd ro g en su lf id e, o r o th er g as es p o is o n in g b y b en ze n e, b en zo l, ca rb o n te tr ac h lo ri d e, o r o th er o rg an ic so lv en ts p o is o n in g b y in se ct ic id e sp ra ys su ch as p ar at h io n o r le ad ar se n at e;
p o is o n in g b y o th er ch em ic al s, su ch as fo rm al d eh yd e.
E xa m p le s:
b en ig n tu m o rs h is to p la sm o si s;
co cc id io id o m yc o si s.
,a n d th e em p lo ye e’ s to ta l h ea ri n g le ve l is d ec ib el s (d
B o r m o re ab o ve au d io m et ri c ze ro
(a ls o av er ag ed at an d h er tz in th e sa m e ea r( s)
W h e n m u st y o u p o st t h e
S u m m a ry
H o w l o n g m u st y o u k e e p t h e L o g a n d S u m m a ry o n f il e
D o y o u h a ve t o s e n d t h e se f o rm s to O
S H
A a t th e e n d o f th e y e a r?
H o w c a n w e h e lp y o u
Y o u m u st p o st th e o n ly n o t th e b y
F eb ru ar y o f th e ye ar fo ll o w in g th e ye ar co ve re d b y th e fo rm an d k ee p it p o st ed u n ti l
A p ri l o f th at ye ar
Y o u m u st k ee p th e an d fo r ye ar s fo ll o w in g th e ye ar to w h ic h th ey p er ta in
N o
Y o u d o n o t h av e to se n d th e co m p le te d fo rm s to
O S
H A u n le ss sp ec if ic al ly as k ed to d o so
If yo u h av e a q u es ti o n ab o u t h o w to fi ll o u t th e o r
S u m m ar y
L og
L og
S u m m ar y
L og vi si t u s o n li n e a t w w w .o sh a
.g o v c a ll y o u r lo c a l O
S H
A o ff ic e
W a t is a n i n c id e n c e r a te
H o w d o y o u c a lc u la te a n i n c id e n c e ra te
W h a t c a n I c o m p a re m y in c id e n c e ra te t o
A n in ci d en ce ra te is th e n u m b er o f re co rd ab le in ju ri es an d il ln es se s o cc u rr in g am o n g a g iv en n u m b er o f fu ll
-t im e w o rk er s
(u su al ly fu ll ti m e w o rk er s) o ve r a g iv en p er io d o f ti m e
(u su al ly o n e ye ar
T o ev al u at e yo u r fi rm
’s in ju ry an d il ln es s e x p er ie n ce o ve r ti m e o r to co m p ar e yo u r fi rm
’s e x p er ie n ce w it h th at o f yo u r in d u st ry as a w h o le yo u n ee d to co m p u te yo u r in ci d en ce ra te
B ec au se a sp ec if ic n u m b er o f w o rk er s an d a sp ec if ic p er io d o f ti m e ar e in vo lv ed th es e ra te s ca n h el p yo u id en ti fy p ro b le m s in yo u r w o rk p la ce an d
/o r p ro g re ss yo u m ay h av e m ad e in p re ve n ti n g w o rk re la te d in ju ri es an d il ln es se s.
Y o u ca n co m p u te an o cc u p at io n al in ju ry an d il ln es s in ci d en ce ra te fo r al l re co rd ab le ca se s o r fo r ca se s th at in vo lv ed d ay s aw ay fr o m w o rk fo r yo u r fi rm q u ic k ly an d ea si ly
T h e fo rm u la re q u ir es th at yo u fo ll o w in st ru ct io n s in p ar ag ra p h
(a b el o w fo r th e to ta l re co rd ab le ca se s o r th o se in p ar ag ra p h (b fo r ca se s th at in vo lv ed d ay s aw ay fr o m w o rk fo r b o th ra te s th e in st ru ct io n s in p ar ag ra p h (c
(a co u n t th e n u m b er o f li n e en tr ie s o n yo u r
O S
H A
F o rm o r re fe r to th e O
S H
A F o rm
A an d su m th e en tr ie s fo r co lu m n s (G
(H
(I an d
(J
(b co u n t th e n u m b er o f li n e en tr ie s o n yo u r
O S
H A
F o rm th at re ce iv ed a ch ec k m ar k in co lu m n
(H o r re fe r to th e en tr y fo r co lu m n
(H o n th e
O S
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F o rm
A
(c
R ef er to O
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A F o rm
A an d o p ti o n al w o rk sh ee t to ca lc u la te th is n u m b er
Y o u ca n co m p u te th e in ci d en ce ra te fo r al l re co rd ab le ca se s o f in ju ri es an d il ln es se s u si n g th e fo ll o w in g fo rm u la
(T h e
,0 fi g u re in th e fo rm u la re p re se n ts th e n u m b er o f h o u rs em p lo ye es w o rk in g h o u rs p er w ee k w ee k s p er ye ar w o u ld w o rk an d p ro vi d es th e st an d ar d b as e fo r ca lc u la ti n g in ci d en ce ra te s.
Y o u ca n co m p u te th e in ci d en ce ra te fo r re co rd ab le ca se s in vo lv in g d ay s aw ay fr o m w o rk d ay s o f re st ri ct ed w o rk ac ti vi ty o r jo b tr an sf er
(D A
R T u si n g th e fo ll o w in g fo rm u la
Y o u ca n u se th e sa m e fo rm u la to ca lc u la te in ci d en ce ra te s fo r o th er va ri ab le s su ch as ca se s in vo lv in g re st ri ct ed w o rk ac ti vi ty (c o lu m n
(I o n
F o rm
A ca se s in vo lv in g sk in d is o rd er s
(c o lu m n (M
-2 o n
F o rm
A et c.
Ju st su b st it u te th e ap p ro p ri at e to ta l fo r th es e ca se s, fr o m F o rm
A in to th e fo rm u la in p la ce o f th e to ta l n u m b er o f in ju ri es an d il ln es se s.
T h e B u re au o f L ab o r S ta ti st ic s (B
L S co n d u ct s a su rv ey o f o cc u p at io n al in ju ri es an d il ln es se s ea ch ye ar an d p u b li sh es in ci d en ce ra te d at a b y va ri o u s cl as si fi ca ti o n s
(e .g b y in d u st ry b y em p lo ye r si ze et c.
Y o u ca n o b ta in th es e p u b li sh ed d at a at w w w .b ls .g o v/ ii f o r b y ca ll in g a
B L
S R eg io n al
O ff ic e.
an d
To fi n d ou t th e to ta l n u m be r of re co rd ab le in ju ri es an d il ln es se s th at oc cu rr ed du ri n g th e ye ar
To fi n d ou t th e n u m be r of in ju ri es an d il ln es se s th at in vo lv ed da ys aw ay fr om w or k, T he n u m be r of ho u rs al l em pl oy ee s ac tu al ly w or ke d du ri n g th e ye ar
To ta l n u m be r of in ju ri es an d il ln es se s ,0
N u m be r of ho u rs w or ke d by al l em pl oy ee s
To ta l re co rd ab le ca se ra te
(N u m be r of en tr ie s in co lu m n H
N u m be r of en tr ie s in co lu m n I)
,0
N u m be r of ho u rs w or ke d by al l em pl oy ee s
D
A R
T in ci de n ce ra te
X
X
O p ti o n a l
C a lc u la ti n g
I n ju ry a n d I ll n e ss
I n c id e n c e
R a te s
W o rk sh e e t
U.S. Department of Labor Occupational Safety and Health Administration
N u m b er o f en tr ie s in
C o lu m n H
C o lu m n I
D A
R T in ci d en ce ra te
N u m b er o f h o u rs w o rk ed b y al l em p lo ye es
T o ta l n u m b er o f in ju ri es an d il ln es se s
X
,0
T o ta l re co rd ab le ca se ra te
N u m b er o f h o u rs w o rk ed b y al l em p lo ye es
X
,0 e is u se d to cl as si fy w o rk -r el at ed in ju ri es an d il ln es se s an d to n o te th e e x te n t an d se ve ri ty o f ea ch ca se
W h en an in ci d en t o cc u rs u se th e to re co rd sp ec if ic d et ai ls ab o u t w h at h ap p en ed an d h o w it h ap p en ed
W e h av e g iv en yo u se ve ra l co p ie s o f th e in th is p ac k ag e.
If yo u n ee d m o re th an w e p ro vi d ed yo u m ay p h o to co p y an d u se as m an y as yo u n ee d
T h e a se p ar at e fo rm sh o w s th e w o rk -r el at ed in ju ry an d il ln es s to ta ls fo r th e ye ar in ea ch ca te g o ry
A t th e en d o f th e ye ar co u n t th e n u m b er o f in ci d en ts in ea ch ca te g o ry an d tr an sf er th e to ta ls fr o m th e to th e T h en p o st th e in a vi si b le lo ca ti o n so th at yo u r em p lo ye es ar e aw ar e o f in ju ri es an d il ln es se s o cc u rr in g in th ei r w o rk p la ce
L og of W or k-
R el at ed
In ju ri es an d
Il ln es se s
L og
L og
S u m m ar y
L og
S u m m ar y.
S u m m ar y
If yo u r co m p an y h as m o re th an o n e es ta b li sh m en t o r si te yo u m u st k ee p se p ar at e re co rd s fo r ea ch p h ys ic al lo ca ti o n th at is e x p ec te d to re m ai n in o p er at io n fo r o n e ye ar o r lo n g er
Y o u d o n
’t p o st t h e L o g
Y o u p o st o n ly th e
S u m m a ry a t th e e n d o f th e y e a r.
H o w t o F il l O u t th e
L o g
U.S. Department of Labor Occupational Safety and Health…
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