A.03.17 Cleaning Services Exhibits.pdf

List of Exhibits

A. Items to be Delivered at Least One Week Prior to Pre-Work Conference

B. Cleaning Maps

C. Approximate Quantities by Area

D. Safety Plan Outline

E. Partial Listing of Safety Requirements

F. Safety Forms CELRH 2796, Eng. 3394

• CELRH Form 2642 – Activity Hazard Analysis

• OSHA’s Form 300A – Work Related Injuries

• ENG Form 3394 – Accident Investigation Report

G. Quality Control Plan

H. Quality Assurance Surveillance Plan (QASP)

I. Sample Work Schedule

J. Sample Invoice

K. Government Furnished Equipment List

L. Task Order, DD 1449

M. Job Request Form, CELRH 2770

N. Contract Discrepancy Form, DD 1104

O. Contractor Equipment and Supply Inspection, Form 2800

P. Vehicle Operations

• CELRH Form 2813 – Administrative Vehicle Operation Record

• CELRH Form 2796 – Equipment Pre-operational Checklist

• ENG Form 4900R – Property Control Receipt

• ENG Form 4866 – Interim Hand Receipt

Q. Inspection Forms:

• ENG Form 5007 – Equipment Inspection/Maintenance Worksheet

• CELRH Form 2773 – Inspection Checklist, Cleaning Services Recreation Areas

• CELRH Form 2788 – Playground Inspection Checklist

• CELRH Form 2790 – Swimming Beach Inspection Checklist

R. Pesticide Application Record, CELRH 1031

EXHIBIT A

Items to be Delivered at Least One Week Prior to Pre-Work Conference

Exhibit A

Contractor shall provide the following at least one (1) week prior to the pre-work conference:

A. Schedule of Cleanings. The schedule provided by the Contractor shall be of sufficient detail to allow the Government to inspect all items of work covered under Section C-3 and Section C-4 of the contract as they are being performed (See Exhibit K). Schedule should include daily and non-daily items.

B. Quality Control Plan. A suggested outline for the Contractor’s Quality Control Plan is contained in Exhibit G.

C. Contractor Representatives. List of names of Contractor Representatives and contact information.

D. Contractor Quality Control Inspector. List of Quality Control Inspectors.

E. Contractor Safety Plan. A suggested outline for the Contractor Safety Plan is contained in Exhibit

D.

F. Emergency Contacts. A prioritized list, including phone numbers, of those persons (normally

Contractor Representatives) to call in case of emergencies.

G. Emergency Work Personnel. A list of names, addresses, and telephone numbers of persons who will be available for emergency work.

H. Operators. A list of qualified equipment operators, their qualifications, experience, and certifications for government furnished equipment.

I. CDL License. A list of individuals with valid CDL operator’s license with endorsements.

J. First Aid and CPR. First Aid and CPR certified individuals on each work crew.

Above documents shall be typed and legible.

EXHIBIT B

PROJECT MAPS

EXHIBIT B MAP 1

EXHIBIT B MAP 2

EXHIBIT B MAP 3

EXHIBIT C

APPROXIMATE QUANTITIES BY AREA

APPROXIMATE QUANTITIES BY AREA

DELAWARE LAKE

Item Trail (C)

Acres to be maintained 1

Benches -

Drinking Fountains -

Fish Cleaning Station -

Grills -

Mow and Trim (approx. acres) -

Parking Areas (sq. yds.) -

Picnic Shelters -

Picnic Tables -

Playground Equipment (sets) -

Restrooms -

Shoreline (approx. linear ft.) -

Trails (approx. distance mi.) 0.5

Trash Receptacles 1

Bulletin Board/Kiosk -

Recreation Dam

Item Area (A) Area (B)

Acres to be maintained 16 6

Benches 5 -

Drinking Fountains 3 -

Fish Cleaning Station 0 -

Grills 15 -

Mow and Trim (approx. acres) - -

Parking Areas (sq. yds.) 10,000 -

Picnic Shelters 2 -

Picnic Tables 35 -

Playground Equipment (sets) 2 -

Restrooms 2 -

Shoreline (approx. linear ft.) 3,000 2000

Trails (approx. distance mi.) 1/2 -

Trash Receptacles 35 -

Bulletin Board/Kiosk 3 -

EXHIBIT D

Safety Plan Outline

EM 385-1-1

15 Sep 08

APPENDIX A

APPENDIX A

MINIMUM BASIC OUTLINE FOR ACCIDENT PREVENTION PLANS

An Accident Prevention Plan (APP) is a safety and health policy and program document. The following areas are typically addressed in an APP, but an APP shall be job-specific and shall also address any unusual or unique aspects of the project or activity for which it is written.

The APP shall interface with the employer’s overall safety and health program, and a copy shall be available on the work site. Any portions of the overall safety and health program that are referenced in the APP shall be included as appropriate. ANSI/ASSE A10.38 should be referenced for Programmatic Issues.

> For LIMITED-SCOPE SERVICE, SUPPLY AND R&D CONTRACTS, for example, mowing (only), park attendant, rest room cleaning, the Contracting Officer and SOHO may allow an ABBREVIATED

APP (customized APP requirements and waive the more stringent elements of this section). > See

01.A.11, and Appendix A, paragraph 11.

1. SIGNATURE SHEET. Title, signature, and phone number of the following:

a. Plan preparer (Qualified Person, Competent Person, such as corporate safety staff person, QC);

b. Plan must be approved, by company/corporate officers authorized to obligate the company;

c. Plan concurrence (e.g., Chief of Operations, Corporate Chief of Safety, Corporate Industrial

Hygienist, project manager or superintendent, project safety professional, project QC). Provide concurrence of other applicable corporate and project personnel (Contractor).

2. BACKGROUND INFORMATION. List the following:

a. Contractor;

b. Contract number;

c. Project name;

d. Brief project description, description of work to be performed, and location; phases of work anticipated (these will require an AHA).

3. STATEMENT OF SAFETY AND HEALTH POLICY. Provide a copy of current corporate/company

Safety and Health Policy Statement, detailing commitment to providing a safe and healthful workplace for all employees. The Contractor’s written safety program goals, objectives, and accident experience goals for this contract should be provided.

4. RESPONSIBILITIES AND LINES OF AUTHORITIES. Provide the following:

a. A statement of the employer’s ultimate responsibility for the implementation of his SOH program;

b. Identification and accountability of personnel responsible for safety at both corporate and project level. Contracts specifically requiring safety or industrial hygiene personnel shall include a copy of their resumes. Qualifications shall include the OSHA 30-hour course or equivalent course areas as listed here:

(1) OSH Act/General Duty Clause;

(2) 29 CFR 1904, Recordkeeping;

(3) Subpart C: General Safety and Health Provisions, Competent Person;

(4) Subpart D: Occupational Health and Environmental Controls, Citations and Safety Programs;

(5) Subpart E: PPE, types and requirements for use;

(6) Subpart F: understanding fire protection in the workplace;

(7) Subpart K: Electrical;

(8 Subpart M: Fall Protection;

(9) Rigging, welding and cutting, scaffolding, excavations, concrete and masonry, demolition; health hazards in construction, materials handling, storage and disposal, hand and power tools, motor vehicles, mechanized equipment, marine operations, steel erection, stairways and ladders, confined spaces or any others that are applicable to the work being performed.

c. The names of Competent and/or Qualified Person(s) and proof of competency/qualification to meet specific OSHA Competent/Qualified Person(s) requirements must be attached. The District SOHO will review the qualifications for acceptance;

d. Requirements that no work shall be performed unless a designated competent person is present on the job site;

e. Requirements for pre-task safety and health analysis;

f. Lines of authority;

g. Policies and procedures regarding noncompliance with safety requirements (to include disciplinary actions for violation of safety requirements) should be identified;

h. Provide written company procedures for holding managers and supervisors accountable for safety.

5. SUBCONTRACTORS AND SUPPLIERS. If applicable, provide procedures for coordinating SOH activities with other employers on the job site:

a. Identification of subcontractors and suppliers (if known);

b. Safety responsibilities of subcontractors and suppliers.

6. TRAINING.

a. Requirements for new hire SOH orientation training at the time of initial hire of each new employee.

b. Requirements for mandatory training and certifications that are applicable to this project (e.g., explosive actuated tools, confined space entry, crane operator, diver, vehicle operator, HAZWOPER training and certification, PPE) and any requirements for periodic retraining/recertification.

c. Procedures for periodic safety and health training for supervisors and employees.

d. Requirements for emergency response training. > See paragraph 9.b. below for a list of requirements that may require emergency response training.

7. SAFETY AND HEALTH INSPECTIONS.

a. Specific assignment of responsibilities for a minimum daily job site safety and health inspection during periods of work activity: Who will conduct (e.g., SSHO, PM, safety professional, QC, supervisors, employees – depends on level of technical proficiency needed to perform said inspections), proof of inspector’s training/qualifications, when inspections will be conducted, procedures for documentation, deficiency tracking system, and follow-up procedures;

b. Any external inspections/certifications that may be required (e.g., USCG).

8. ACCIDENT REPORTING. The Contractor shall identify person(s) responsible to provide the following:

a. Exposure data (man-hours worked);

b. Accident investigations, reports, and logs: Report all accidents as soon as possible but not more than 24 hours afterwards to the Contracting Officer/Representative (CO/COR). The contractor shall thoroughly investigate the accident and submit the findings of the investigation along with appropriate corrective actions to the CO/COR in the prescribed format as soon as possible but no later than five (5) working days following the accident. Implement corrective actions as soon as reasonably possible;

c. The following require immediate accident notification:

(1) A fatal injury;

(2) A permanent total disability;

(3) A permanent partial disability;

(4) The hospitalization of three or more people resulting from a single occurrence;

(5) Property damage of $200,000 or more.

9. PLANS (PROGRAMS, PROCEDURES) REQUIRED BY THE SAFETY MANUAL. Based on a risk assessment of contracted activities and on mandatory OSHA compliance programs, the Contractor shall address all applicable occupational risks and compliance plans. Using the EM 385-1-1 as a guide, plans may include but not be limited to:

a. Layout plans (04.A.01);

b. Emergency response plans:

(1) Procedures and tests (01.E.01);

(2) Spill plans (01.E.01, 06.A.02);

(3) Firefighting plan (01.E.01, Section 19);

(4) Posting of emergency telephone numbers (01.E.05);

(5) Man overboard/abandon ship (Section19.A.04);

(6) Medical Support. Outline on-site medical support and off-site medical arrangements including rescue and medical duties for those employees who are to perform them, and the name(s) of on-site

Contractor personnel trained in first aid and CPR. A minimum of two employees shall be certified in CPR and first-aid per shift/site (Section 03.A.02; 03.D);

c. Plan for prevention of alcohol and drug abuse (01.C.02);

d. Site sanitation plan (Section 02);

e. Access and haul road plan (4.B);

f. Respiratory protection plan (05.G);

g. Health hazard control program (06.A);

h. Hazard communication program (06.B.01);

i. Process Safety Management Plan (06.B.04);

j. Lead abatement plan (06.B.05 & specifications);

k. Asbestos abatement plan (06.B.05 & specifications);

l. Radiation Safety Program (06.E.03.a);

m. Abrasive blasting (06.H.01);

n. Heat/Cold Stress Monitoring Plan (06.I.02)

o. Crystalline Silica Monitoring Plan (Assessment) (06.M) ;

p. Night operations lighting plan (07.A.08);

q. Fire Prevention Plan (09.A);

r. Wild Land Fire Management Plan (09.K);

s. Hazardous energy control plan (12.A.01);

t. Critical lift Plan (16.H);

u. Contingency plan for severe weather (19.A.03);

v. Float Plan (19.F.04);

w. Site-Specific Fall Protection & Prevention Plan (21.C);

x. Demolition plan (to include engineering survey) (23.A.01);

y. Excavation/trenching plan (25.A.01);

z. Emergency rescue (tunneling) (26.A.);

aa. Underground construction fire prevention and protection plan (26.D.01);

bb. Compressed air plan (26.I.01);

cc. Formwork and shoring erection and removal plans (27.C);

dd. PreCast Concrete Plan (27.D);

ee. Lift slab plans (27.E);

ff. Steel erection plan (27.F.01);

gg. Site Safety and Health Plan for HTRW work (28.B);

hh. Blasting Safety Plan (29.A.01);

ii. Diving plan (30.A.13);

jj. Confined space Program (34.A).

10. RISK MANAGEMENT PROCESSES. Detailed project-specific hazards and controls shall be provided by an Activity Hazard Analysis (0I.A.13) for each major phase/activity of work.

11. ABBREVIATED APP for LIMITED-SCOPE SERVICE, SUPPLY AND R&D CONTRACTS. If service, supply and R&D contracts with limited scopes are awarded, the contractor may submit an abbreviated Accident Prevention Plan. This APP shall address the following areas at a minimum. If other areas of the EM 385-1-1 are pertinent to the contract, the contractor must assure these areas are addressed as well.

a. Title, signature, and phone number of the plan preparer.

b. Background Information to include: Contractor; Contract number; Project name; Brief project description, description of work to be performed, and location (map); The project description shall provide a means to evaluate the work being done (see AHA requirements in 01.A.13) and associated hazards involved.

Contractor’s APP shall address the identified hazards involved and the control measures to be taken.

c. Statement of Safety and Health Policy detailing their commitment to providing a safe and healthful workplace for all employees.

d. Responsibilities and Lines of Authorities – to include a statement of the employer’s ultimate responsibility for the implementation of his SOH program; Identification and accountability of personnel responsible for safety at all levels to include designated site safety and health officer (SSHO) and associated qualifications. The District SOHO will review the qualifications for acceptance.

e. Training - new hire SOH orientation training at the time of initial hire of each new employee and any periodic retraining/recertification requirements.

f. Procedures for job site inspections - assignment of responsibilities and frequency.

g. Procedures for reporting man-hours worked and reporting and investigating any accidents as soon as possible but not more than 24 hours afterwards to the Contracting Officer/Representative (CO/COR). An accident that results in a fatal injury, permanent partial or permanent total disability shall be immediately reported to the Contracting Officer.

h. Emergency Planning. Employees working alone shall be provided an effective means of emergency communication. This may be cellular phone, two-way radio or other acceptable means. The selected means of communication must be readily available and must be in working condition.

i. Drinking Water provisions, toilet and washing facilities.

j. First Aid and CPR training (at least two employees on each shift shall be qualified/certified to administer first aid and CPR) and provision of first aid kit (types/size).

k. Personal Protective Equipment.

(1) WORK CLOTHING - Minimum Requirements. Employees shall wear clothing suitable for the weather however minimum requirements for work shall be short-sleeve shirt, long pants (excessively long or baggy pants are prohibited) and leather work shoes. If analysis determines that safety-toed (or other protective) footwear is necessary (i.e., mowing, weed eating, chain saw use, etc), they shall be worn.

(2) Eye and Face Protection. Eye and face protection shall be worn as determined by an analysis of the operations being performed HOWEVER, all involved in chain saw use, chipping, stump grinding, pruning operations, grass mowing, weed eating and blowing operations shall be provided safety eyewear

(Z87.1) as a minimum.

(3) Hearing Protection. Hearing protection must be worn by all those exposed to high noise activities (to include grass mowing and trimming, chainsaw operations, tree chipping, stump grinding and pruning).

(4) Head Protection. Hard hats shall comply with ANSI Z89.1 and shall be worn by all workers when a head hazard exists. At a minimum, hard hats shall be worn when performing activities identified in (2) above.

(5) High Visibility Apparel shall comply with ANSI/ISEA 107, Class 2 requirements at a minimum and shall be worn by all workers exposed to vehicular or equipment traffic.

(6) Protective Leg chaps shall be worn by all chainsaw operators.

(7) Gloves of the proper type shall be worn by persons involved in activities that expose the hands to cuts, abrasions, punctures, burns and chemical irritants.

(8) If work is being performed around water and drowning is a hazard, PFDs must be provided and worn as appropriate.

l. Machine Guards and safety devices. Lawn maintenance equipment must have appropriate guards and safety devices in place and operational.

m. Hazardous Substances. When any hazardous substances are procured, used, stored or disposed, a hazard communication program must be in effect and MSDSs shall be available at the worksite. Employees shall have received training in hazardous substances being used. When the eyes or body of any person may be exposed to corrosives, irritants or toxic chemicals, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within 10 seconds of the worksite.

n. Traffic control shall be accomplished in accordance with DOT’s MUTCD.

o. Control of Hazardous Energy (Lockout/Tagout). Before an employee performs any servicing or maintenance on any equipment where the unexpected energizing or startup of the equipment could occur, procedures must be in place to ensure adequate control of this energy.

p. Driving, working on (i.e., working with equipment/mowers) while on slopes, working from/in boats/skiffs, etc shall also be considered and dealt with accordingly

CONTRACTOR QUALITY CONTROL / SECURITY PLAN

(OUTLINE)

1. INSPECTION OF SERVICES. Define the method of inspection for each service in the contract including, but not limited to: the individual(s) who shall inspect the service (Quality Control Inspectors); when or with what frequency inspections shall be performed (e.g. at the completion of each task, etc.); and a copy of the Contractor's inspection forms or other documents identifying the specific tasks involved in the service which shall be inspected.

2. DEFICIENCIES AND CORRECTIVE ACTION. Explain the procedures for identifying deficiencies in the quality of services provided and methods of correction, before the level of performance is unacceptable.

3. RECORDS. Define the method for maintaining records of inspections and records of corrective actions taken, the individual responsible for the records, and the location where the records shall be kept.

4. QUALITY CONTROL INSPECTORS. A consolidated list of authorized Quality Control Inspectors.

5. CONTRACTOR REPRESENTATIVES. A list of names and phone numbers of authorized Contractor

Representatives.

6. SECURITY. Define and explain the procedures and safeguards which shall be used to protect all equipment, materials, supplies, tools, and other resources provided by the Government to the Contractor including; but not limited to, Contractor audit procedures and inventory systems, if appropriate. Examples of procedures and safeguards include:

a. All pilferable materials shall be kept under constant surveillance and shall be collected at the end of each work day and secured under lock.

b. Keys shall be removed from all vehicles and equipment when not in use.

c. All gates and doors which were opened to allow Contractor personnel access for work shall be closed and locked. Only authorized Contractor personnel or Government personnel shall be permitted to enter secured areas. The COR or his representative shall be informed immediately if any unauthorized person enters a secured area.

EXHIBIT E

PARTIAL LISTING OF SAFETY AND SECURITY

REQUIREMENTS

Exhibit E

PARTIAL LISTING OF SAFETY AND SECURITY REQUIREMENTS

1. The following is a clarification of the Corps of Engineers' policy concerning the use of personal protective equipment for contract employees as defined in the EM 385-1-1, Safety and Health Requirements Manual. This is not meant to be a complete review of required safety equipment, but is simply provided to answer some of the more common questions concerning our safety policy.

The items of equipment listed below should be issued to each employee or made readily available for employee's use, when the work environment requires it:

a. Safety shoes - All employees except park aids performing traffic surveys and clerical personnel are to wear hard toe safety shoes at all times. For those not required to wear steel toed safety shoes, leather work shoes shall be worn.

b. Hard hats - Hard hats are to be worn when operating or working around equipment that lifts overhead (e.g.

backhoe-end loader) or working at ground level around mowing equipment. Hard hats will not be required when operating a riding mower, unless other mowing equipment is present. Hard hats will be required during construction type activities and wildfire suppression.

c. Safety glasses or goggles - Safety glasses with side shields or goggles are to be worn when operating equipment or working around equipment that may cause harm from flying debris (e.g. weed eaters), and when using power or hand tools.

d. Welders - Full face welder's helmets are to be worn during electric arc welding operations, and appropriate shields or warning shall be given or posted to protect other persons from the flash. During oxyacetylene welding or cutting, appropriate goggles or full face shield shall be worn.

e. Gloves - The proper type gloves are to be worn when there is a danger of burns, cuts, scrapes, scratches, wood splinters, or other injury to employee's hands.

f. Ear protection - Ear plugs or muffs shall be worn when operating any device that has been determined to produce 85 decibels or greater on a time-weighted average. It is the

Contractor’s responsibility to determine the noise level of your equipment. Each piece of equipment that exceeds

85dB(A) rating should be labeled to indicate the need for hearing protection.

g Protective leg chaps - Protective leg chaps are to be worn when operating equipment such as a chain saw.

h. P.F.D's (Personal Flotation Device/Life Jacket) - P.F.D's are to be worn at all times when working around the water or on board watercraft.

i. Safety cans - Containers for flammable liquids shall be labeled and meet the requirements specified in Section 9.B.

j. Seat belts - Seat belts are to be worn at all times when operating, or being transported by motor vehicles and when operating mobile equipment with rollover protection.

k. Safety vests - High-visibility apparel meeting, at minimum, ANSI/ISEA 07-2004 Performance Class 2 requirements, shall be worn when employees are working along roadways.

l. Lock-Out/Tag-Out - Lock-Out/Tag-Out procedures will be used in accordance with EM385-1-1, Section 12 and in coordination with project personnel.

m. Respiratory Protection - For work involving hazardous atmospheres, Contractors will provide a written

Respiratory Protection Plan, which includes training and medical clearance. Section 05.G

2. The Contractor shall conduct monthly safety meetings and weekly "tool box" safety meetings in accordance with

EM 385-1-1, Safety and Health Requirements Manual. The Contractor may contact the COR about upcoming work planned, to determine appropriate subjects for the monthly safety meetings. The Government makes no guarantee that the list of upcoming work planned, will actually be ordered nor will work ordered be restricted to said list. The

Contractor shall inform the COR of the date, time, and place of the monthly safety meeting, a minimum of 7 days prior to the meeting.

3. Great emphasis will be given to the development and proper use of Activity Hazard Analysis (AHA). When ordered, AHAs will be developed in detail, utilized during job performance, and available to employees at the job site.

4. Transporting employees and equipment to worksites:

a. Vehicles used to transport staff and equipment must be well maintained and never overloaded. Each vehicle occupant must have a seat belt available to him or her and must wear the belt.

b. Personnel and tools must be kept apart during travel. Tools and tool boxes must be secured in a manner which will prevent their causing injury in case of a sudden stop or collision.

c. Tool box lids must be securely latched or locked.

5. Contractor vehicles involved in liter pick-up along project and public roads must be equipped with an orange rooftop revolving light, a rear mounted warning sign and reflective warning tape on the bumper. Employees performing liter pickup along public and project roads must wear High-visibility apparel meeting, at minimum, ANSI/ISEA 07-2004 Performance Class 2 requirements.

SECURITY REQUIREMENTS

1. The Contractor shall cooperate with the Government in providing for the security of Government property. Some examples of the security measures expected include:

a. Closing and locking all gates and doors which were opened to allow Contractor personnel access for work.

b. Ensure that only Government personnel or authorized Contractor personnel enter secured areas. The COR or his representative shall be informed immediately if any unauthorized persons enter a secured area.

c. Secure or maintain constant surveillance on all pilfer able items to prevent theft. Provide control to ensure that

Government furnished equipment, property, or materials are utilized only for contract-purposes.

EXHIBIT F

SAMPLE SAFETY FORMS

Activity Hazard Analysis Checklist

CELRH Form 2642

OSHA 300 Log Instructions

OSHA 300 Log OSHA

300A Log

ACTIVITY HAZARD ANALYSIS CHECKLIST

1. Are all blocks in the top 1/3 of the form completed including:

Project:

Date: Job:

Estimated Starting Date:

Prepared by:

Recommended Protective Clothing and Equipment: Reviewed by:

Page of

Positions Assigned to do Job:

2. Does the “Job" block include the job request number and sufficiently descriptive information to understand the tasks to be performed?

3. Is all the protective equipment necessary for all phases of the work listed in PART I?

4. Are all job steps listed and numbered consecutively in Part I including if applicable but not limited to:

a. Inspection of equipment and safety gear.

b. Loading and unloading of personnel and equipment.

c. Transportation to and from the job site.

d. Setting up equipment and safety markers.

e. Performance of tasks.

f. Securing job site while it is unattended.

g. Clean-up and storage of safety gear and equipment.

5. Are all hazards associated with each job step in Part I listed in Part II opposite the appropriate job step?

Hazards may include but are not limited to:

a. Potential injuries during loading and unloading of equipment.

b. Potential injuries from improperly loaded and/or secured equipment and vehicles during transportation to and from job site.

EXHIBIT C

c. Potential injuries from failure to follow defensive driving procedures or wear seat belts and shoulder harnesses to and from job site.

d. Potential electrical shock and/or fire hazards.

e. Potential injuries from improperly maintained or guarded equipment and vehicles.

f. “Caught between" injuries such as pinched fingers and/or hands or smashed feet.

g. Potential injuries to public and/or workers due to inadequate set up at job site prior to, during and after work.

h. Slips, trips and falls.

i. Potential injuries from improper, unsafe or careless performance of tasks including improper lifting or overexertion.

j. Potential injuries from failure to use appropriate personal protective gear.

k. Natural hazards such as moving water, falling tree limbs, rock slides, etc.

l. Contact with poisonous or harmful substances.

6. Does Part III contain an appropriate action to prevent injuries from every hazard listed in Part II? Note this section should avoid general safety clichés such as "Be alert." Part III should be specific as to what the worker should do to avoid injury associated with each hazard. Safety clichés or generalities are OK if they are included with the specific directions for avoidance of a particular hazard. However, they cannot stand alone as a Part III ACTION to avoid a Part

II HAZARD. An example of appropriate usage of a safety generality would be: "Be alert. W atch for members of the public wandering into mowing area. Immediately stop machine. Do not resume operation until area is clear of people."

Utilizing the Risk Assessment Matrix in the upper right hand corner assess the risk for each job step, the actions indicated to reduce that risk and finally the overall risk associated with this activity. Assign a Risk Assessment Code for the overall activity in the upper right hand corner to complete the Hazard Analysis.

This checklist should be utilized by other the preparer and reviewer to assure proper completion of the JHA.

NOTE: Get everyone involved with the job to take part in the preparation of the JHA. Oftentimes problems overlooked by one member of a crew will be uncovered by the group. Finally, insure that every member of the work crew has thoroughly reviewed the JHA and is well aware of all the potential hazards so that they can take preventive action before an accident occurs.

ENG FORM 3394, AUG 2021 PREVIOUS EDITIONS ARE OBSOLETE. Page of

U.S. Army Corps of Engineers (USACE)

For use of this form, see instructions in the attachments and USACE ER 385-1-99; the proponent agency is CESO.

Requirement Control Symbol

RCS-CESO-21-0001

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority 10 U.S.C. 7013, Secretary of the Army; 5 U.S.C. 7902, Safety Programs; Public Law 91-596, Occupational Safety and Health Act of 1970; DoD Instruction 6055.1, DoD Safety and Occupational Health Program; Army Regulations 385-10, Army Safety Program;

DoD Instruction 6055 .07, Mishap Notification, Investigation, Reporting, and Record Keeping; and E.O. 9397 (SSN), as amended.

Principal Purpose Information collected is to provide the USACE leaders, soldiers, families and civilians in injury, illness, and loss data to effectively manage its safety and occupational health program.

Routine Uses In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b) as follows: To the Department of Labor, the Federal Aviation Agency, the National Transportation Safety Board, and to Federal, State, and local agencies and applicable civilian organizations, such as the National Safety Council, for use in a combined effort of accident prevention. In some cases, data must also be disclosed to an employee's representative under the provisions of 29 CFR

1960.29. Records will be made available consistent with applicable laws and regulations. Information will be withheld from the public only if authorized by 5 U.S.C. Section 552 (Freedom of Information Act (FOIA), 5 U.S.C. 552a (Privacy Act)), or other statutory or regulatory authority.

Disclosure Failure to provide all the required information on the report may result in the rejection of report submission.

1. WHO IS REPORTING MISHAP

a. Name: b. Phone number:

c. Email address: d. Signature:

e. Report type:

1. Near Miss Report. (No injury/illness, or property damage. Complete all fields with underlined text.) Date:

2. Initial Accident Report. (For accident notification within 24 hrs, Complete all fields with underlined text.) Date:

3. Final Accident Report. (For reporting findings from accident investigation, complete full form.) Date:

f. Mishap Type. (Check all that apply)

Fatality Injury/Illness Property Damage Near Miss

g. Were any of the following items associated with the mishap ? (If yes, check all that apply)Yes No

Electrical and/or Hazardous

Energy Working at Heights Diving

Load Handling Equipment or

Rigging

Occupational Health

Exposure

2. WHO WAS INVOLVED IN THIS MISHAP?

a. Name:

b. Personnel Classification: c. Time employee began work:

d. Gender: e. Date of birth (for Government personnel only): f. Age:

g. Date hired: h. Primary language:

i. Is individual a supervisor? Yes No j. Duty status at time of mishap: k. Years experience in job:

l. What was individual doing when mishap occurred? (Select activity from the drop downs below.)

1. General activities: 2. Vehicle/Equipment/Vessel:

3. Sports/Recreation: 4. Other not listed:

m. Did individual utilize all OSHA/EM 385-1-1 required Personal Protective Equipment (PPE) for activity? Yes No N/A

If no, identify missing PPE:

n. Was a Personal Flotation Device used? Yes No N/A o. Was a seat belt used? Yes No N/A

1 5

ENG FORM 3394, AUG 2021 Page of

p. Government personnel only:

4. Center/Division/Lab: 5. District:

1. Prime Contractor name:

q. Contractor personnel only:

2. Contract number: 3. Contract type: 4. Funding type:

Other not listed:

r. If mishap occurred on a contractor site, provide the following:

1. Employer/Contractor name:

3. Grade:2. Rank:

2. Individual's occupation/trade:

1. Job series:

h. If treatment was given away from the work-site, where was it given? (For Government Personnel Only)

j. Estimated days away from work: k. Estimated days of restricted/transferred duty:

Was OSHA notified?If yes, how many nights? Yes Noi. Was employee hospitalized as an in-patient? Yes No

Country:Zip:State: City:

Address:

Treatment facility name:

g. Was employee treated in an emergency room ? Yes No N/Af. Was treatment given away from work site? Yes No

Source of injury/illness: Cause of injury/illness:

Primary body part affected:

c. Identify body part(s) affected by injury/illness:

b. Type of Injury/Illness:a. Severity of injury/illness?

Secondary body part affected:

d. Identify cause and source of injury/illness:

If yes, provide name of physician or health care professional provider?

e. Was employee treated by a physician or health care professional provider? Yes No

Note: OSHA requires reporting all work-related fatalities within 8 hours and in-patient hospitalizations, amputations and loss of an eye within 24 hours to OSHA.

3. WHAT TYPE OF INJURY/ILLNESS OCCURRED?

4. WHAT HAPPENED?

a. What was the primary activity occurring at the time of the mishap?

Other, not listed:

b. What happened? Provide a detailed description of the mishap. (Do not include any personally identifiable information (name, etc.).)

Note: Provide supporting photos, charts, diagrams, etc. with this report.

c. What other organizations or agencies have been notified about this mishap?

2 5

b. USACE Office/Program/Project name:

a. List all property/material involved in the mishap. (Include damaged and undamaged property.)

i. Type of item:

Item A Item B Item C

ii. Name of item(s):

iv. Ownership of item:

v. Dollar cost of damage:

a. Date the mishap occurred: b. Time mishap occurred:

c. What day did mishap occur on? d. What period of day did mishap occur?

a. Did the mishap occur on a military Base/Post? Yes No

c. Select the location type most closely associated with the mishap:

d. Identify exact location where mishap occurred:

e. Latitude: f. Longitude:

Other not listed:

Other not listed:

iii. Collision type:

Country:Zip:State: City:

Address:

5. WHAT TYPE OF PROPERTY/MATERIAL WAS INVOLVED?

6. WHEN DID THE MISHAP OCCUR?

7. WHERE DID THE MISHAP OCCUR?

8. WHY DID THE MISHAP OCCUR? (Recommend completing this section for Near Misses.)

A. Performance Causal Factors

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

If yes, select the error that contributed most to the mishap:

1. Did a problem with resources contribute to this mishap occurring?

1. Did a problem with performance contribute to this mishap occurring? Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If yes, select the error that contributed most to the mishap:

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

B. Support Causal Factors

C. Standards/Policy/Planning Causal Factors

If yes, select the error that contributed most to the mishap:

1. Did an organizational standard/policy/or plan contribute to this mishap occurring?

2. Was a written Activity Hazard Analysis (AHA) or equivalent completed and accepted by Government Designated Authority (GDA) for task(s) being performed at time of mishap? (If yes, attach a copy to this report)

If yes, was the AHA available and used by worker?

3. Was a written work plan (critical lift plan, fall protection plan, etc.) required, completed and accepted by the GDA for task(s) being performed at time of mishap?

If yes, was the plan available and used by worker?

3 5

4. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

If yes, select the error that contributed most to the mishap:

1. Did any leader/supervisory mistake/task error contribute to this mishap occurring?

If yes, select the error that contributed most to the mishap:

1. Did any individual mistakes/task errors contribute to this mishap occurring?

4. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

3. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

If yes, select the error that contributed most to the mishap:

1. Did any material failure contribute to this mishap occurring?

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

1. Did a problem with training contribute to this mishap occurring?

If yes, select the error that contributed most to the mishap:

If yes, select type of training: Classroom On the jobCertification/License

Other, describe:

What was date of most recent training?

2. Which failure is most closely associated with the material failure/malfunction?

If yes, select the error that contributed most to the mishap:

1. Did any physical environment contribute to this mishap occurring?

2. Was individual trained to perform the activity/task?

3. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

2. Did the safety climate/culture contribute to the mishap?

3. Did challenges with teamwork contribute to the mishap?

D. Training Causal Factors

E. Leader/Supervisor Causal Factors

F. Individual Causal Factors

G. Physical Environment Causal Factors

H. Material Causal Factors

I. Environmental Causal Factors

If yes, select the factor that contributed most to the mishap:

1. Did any environmental condition contribute to this mishap occurring?

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

4 5

2. Describe action(s) taken, anticipated or recommended to eliminate hazard:

If yes, describe:

1. Did the design of the facility/building contribute to the mishap?

J. Facility/Building Design

b. Who is responsible for the corrective action plan?

a. Have all corrective action(s) to prevent mishap recurrence been completed?

c. What date will/have all corrective action(s) be/been completed by:

d. Additional information:

2. Describe action(s) taken, anticipated or recommended to eliminate hazard(s):

If yes, describe the hazard(s):

1. Did a hazard(s) contribute to the mishap?

K. Existing Hazard

9. Corrective Action plan

10. Additional Information

Yes No

Yes No

Yes No

5 5

Exhibit G

Quality Control Plan

CONTRACTOR QUALITY CONTROL PLAN (OUTLINE)

1. INSPECTION OF SERVICES. Define the method of inspection for each service in the contract including, but not limited to: the individual(s) who shall inspect the service (Quality Control

Inspectors); when or with what frequency inspections shall be performed (e.g. at the completion of each task, etc.); and a copy of the Contractor's inspection forms or other documents identifying the specific tasks involved in the service which shall be inspected.

2. DEFICIENCIES AND CORRECTIVE ACTION. Explain the procedures for identifying deficiencies in the quality of services provided and methods of correction, before the level of performance is unacceptable.

3. RECORDS. Define the method for maintaining records of inspections and records of corrective actions taken, the individual(s) responsible for the records, and the location where the records shall be kept.

4. QUALITY CONTROL INSPECTORS. A consolidated list of authorized Quality Control

Inspectors.

5. CONTRACTOR REPRESENTATIVES. A list of names and phone numbers of authorized

Contractor Representatives.

6. SECURITY. Define and explain the procedures and safeguards which shall be used to protect all equipment, materials, supplies, tools, and other resources provided by the Government to the

Contractor including; but not limited to, Contractor audit procedures and inventory systems, if appropriate. Examples of procedures and safeguards include:

a. All pilferable materials shall be kept under constant surveillance and shall be collected at the end of each work day and secured under lock.

b. Keys shall be removed from all vehicles and equipment when not in use.

c. All gates and doors which were opened to allow Contractor personnel access for work shall be closed and locked. Only authorized Contractor personnel or Government personnel shall be permitted to enter secured areas. The COR or his representative shall be informed immediately if any unauthorized person enters a secured area.

EXHIBIT H

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR CLEANING CONTRACT, DELAWARE LAKE, OHIO

APPROVED BY: DATE:

CONTRACTING OFFICER

PART I. INTRODUCTION

A. General. This plan will be used to assure the government that work specified under this contract is completed satisfactorily. The plan is included for information purposes only. It does not supersede any of the requirements in other sections of the contract. Surveillance or inspections will be primarily conducted in three ways; however, the Government has the right to change or modify inspection methods at its discretion. The three principle inspection methods are random, one-hundred percent, and planned. In conjunction with describing the principle methods used for providing surveillance

(i.e. inspecting), this plan defines common terms and acronyms; summarizes in table form the performance requirements for each contract section; summarizes in table form a “sampling guide” for each contract section; explains how deductions for unsatisfactory performance are calculated; and, provides examples of Inspection Checklists.

Do not confuse the Quality Assurance Program with the Quality Control Program. The Government uses the Quality

Assurance Program; while the Contractor uses the Quality Control Program.

B. Roles and Responsibilities. The following personnel shall oversee and coordinate surveillance activities.

1. Procuring Contracting Officer (PCO) – The PCO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the

United States in the contractual relationship. The PCO shall also ensure that the contractor receives impartial, fair, and equitable treatment under this contract. Determine the final assessment of the contractor’s performance.

2. Contracting Officer’s Representative (COR) The COR is responsible for providing continuous technical oversight of the contractor’s performance. The COR uses the QASP to conduct the oversight/surveillance process. The COR shall keep a Quality Assurance file that accurately documents the contractor's actual performance. The purpose is to ensure that the contractor meets the performance standards contained in the contract. The COR is responsible for reporting early identification of performance problems to the KO. The

COR is required to provide an annual performance assessment to the KO which will be used in documenting past performance. The QASP is the primary tool for documenting contractor performance. The COR is not empowered to make any contractual commitments or to authorize any contractual change on the

Government’s behalf.

3. Other Key Government Personnel. This may include performance monitors, inspectors, or others who provide information that helps the COR monitor contractor performance.

C. Authority. Authority for issuance of this QASP is provided under Part 46 of the Federal Acquisition Regulation, Inspection of Services clauses, which provides for inspection, acceptance, and documentation of the service called for in the contract or order. This acceptance is to be executed by the contracting officer or a duly authorized representative.

D. ACRONYMS AND DEFINITIONS.

1. List of Acronyms.

a. AQL. Acceptable Quality Level.

b. CDR. Contract Discrepancy Report.

c. COR. Contracting Officer Representative.

d. CO/KO. Contracting Officer.

e. PRS. Performance Requirements Summary.

f. PWS. Performance Work Statement.

g. QA. Quality Assurance.

h. QAE. Quality Assurance Evaluator (i.e., an Inspector).

i. QASP. Quality Assurance Surveillance Plan.

j. QC. Quality Control.

k. QCP. Quality Control Plan.

l. N/A. Non-Applicable

2. Definitions.

a. Acceptable Quality Level. Predetermined value used by the Government to distinguish between satisfactory and unsatisfactory performance. AQL may be stated in present and is the maximum number of defects per 100 units that can be considered satisfactory. As long as the defective performance does not exceed the AQL, the total service will not be rejected by the Government. The contractor, however, must re-perform the defective service.

b. Defect. A deficiency(s) serious enough to render a service unacceptable.

c. Deficiency. Any inspection unit which does not meet the contract requirements in their entirety.

d. Inspection Unit. For statistical sampling the unit is identified in the sampling guide. For all other work the inspection unit is the job. The inspection unit may include several tasks.

e. Inspector. Individual designated by the COR to perform Quality Assurance.

f. Item. The term item, when used with the contract, refers to the Contract Line Item Number (CLIN) contained in the price breakout schedule.

g. Job. A job describes an individual, separate, and defined element of work to be performed. “Mowing the Below Dam Recreation Area” is an example of a job.

h. Lot Size. The total number of times the service is performed in a given period of time, such as the total number of cleanings per month. Also called a population.

i. 100% Inspection. An inspection method requiring the examination of each completed job. It is not required that the inspector be at the job site 100 percent of the time while the job is occurring.

j. Percent of Sample Found Defective. Determined by dividing the number of defects by the sample size.

k. Planned Sampling. An evaluation method designed to inspect some part of but not necessarily all of the contract requirements. Sample selection is based on some subjective rationale and sample size is usually arbitrarily determined.

l. Quality Assurance. Those actions taken by the Government to insure goods or services meet the requirements of the contract.

m. Quality Assurance Evaluator. A Government official responsible for evaluating contractor's performance.

Also, known as an inspector.

n. Quality Control. Those actions taken by a contractor to control the production of goods or services to insure that they meet the requirements of the contract.

o. Random Number Table. A table of numbers arranged in a random fashion. A table used to make random samples.

p. Random Sample. A sampling method whereby each service output in a lot has an equal chance of being selected, or where any occurrence of a contract requirement is as likely to be evaluated as any other occurrence.

q. Random Sampling. A method of looking at a few individual items in a lot to determine the quality of that lot against a standard.

r. Reject Level. The number of defects beyond which the total service for that lot is rejected by the

Government and deductions are made for unsatisfactory performance. The contractor must re-perform defective services, when possible, even if the number of defects is less than the reject level.

s. Sample. A sample consists of one or more service outputs drawn from a lot, the outputs being chosen at random. The number of outputs in the sample is the sample size.

t. Sampling Guide. The part of the surveillance plan which contains all the information needed to perform a random sample. A "how to inspect guide" for each type of work to be performed.

u. Service Requirement. A job to be performed to the specified standard and within the acceptable quality level. The contractor must do the specific job, meet the standard, and meet the acceptable quality level before performance is acceptable and contractor will be paid.

v. Surveillance Plan. An organized written Government Document used for quality assurance surveillance.

w. Unscheduled Inspection. Impromptu inspections of contract requirements without a pre- planned schedule.

x. Validated Complaints. An evaluation method utilizing customer awareness.

y. Work. The general scope of services covered under the specifications of this contract. SECTION II.

Acceptance/Rejection of Services

Section II. Acceptance/Rejection of Services

A. General. Inspection of all services performed under this contract will primarily be done in accordance with a schedule developed by the Government, and will primarily be done by using one or a combination of the surveillance methods cited in this plan. Tables are included at the end of this plan to show the surveillance methods.

Generally reduced surveillance is used, but if performance is not acceptable, normal or tightened surveillance may be used. The purpose of inspection is to document contractor performance and the quality of services or goods produced. Documentation of contractor performance will be done on the appropriate Inspection

Checklist (see Section VI of this plan).

B. Acceptance.

1. Statistically Sampled Work. Whenever the number of defects for a lot falls at or below the established reject level the work will be considered satisfactory. However, the contractor is still required to correct the deficiencies.

2. 100% Inspection. When all work is performed in accordance with the Task Order.

C. Rejection.

1. Statistically Sampled Work. Whenever the defects exceed the…