A21 - (E) W912PM25QA020 - Attachment 3 - Record of Work-Related Injuries Illnesses and Exposure.pdf

Month Year

City State USACE Office Overseeing Work:

Describe The Case

(B1) (B2) (B3) (C) (D) (F) Enter the number of days the injured or ill worker

Contract Number

Classify the case

Check the "injury" column or choose

Identify the person

(A) (E)

Contractor Name

USACE PRIME CONTRACTOR

USACE Command

US Army Corps of Engineers

Project Title

Using these categories, check ONLY the most

Monthly Record of Work-Related Injuries/Illnesses & Exposure

In accordance with the provisions of EM 385-1-1, Section 01 Program Management, Paragraph 01.D Accident Reporting and Recording, sub-paragraphs 01.D.05, you (the Prime Contractor) shall provide a monthly record of all exposure and accident experience incidental to the work (this includes exposure and accident experience of the Prime Contractor and its sub-contractor(s). As a minimum , these records shall include exposure work hours and a record of occupational injuries and illnesses that include the data elements listed below. Definitional criteria for each data element is found in 29 CFR Part 1904. If the maintenance of OSHA 300 Logs are required by OSHA, most of this information can be obtained from those logs. If data on log provided below is revised after it is submitted to USACE, Contractor shall provide a revised report to the GDA. You must complete the USACE ENG Form 3394, Report of Accident Investigation Report for all recordable accidents. If you're not sure whether a case is recordable, call your local Safety and Occupational Health Office for help.

(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)

0 0 0 0 0 0 0 0 0 0 0 0 Type of Contract (Choose One):

Construction Opn & Main. Civil Works Eng. Services Military Programs Dredging Other Rsch. & Dev.

Emerg. Opns.

Other

Environmental Remed.

__1 of _1__PageEnvironmental Other

FUDS

Date

Exposure Hours Month

Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill (e.g. Second degree burns on right forearm from acetylene torch)

Superfund

TYPE OF WORK ACTIVITY (Choose One):

For Government Use Only

Where the event occurred (e.g. Loading dock north end)Date Employee

Began Work on

Job Covered by Contract

Job Title (e.g., Welder)

(mo./day)

H ea rin g

Lo ss

(M) the injured or ill worker was:

FUSRAP

IRP

Year to Date

Ordinance/Expl. Cleanup

Days away from work

Signature

Certification of Record Name of Person Submit. Record

Date of injury or onset of illness

Check the injury column or choose one type of illness:

Po is on in g

Pr im e or

S ub

(P o r S

Company Name

Al l o th er

Ill ne ss es

On job transfer or restriction (days)

Ag e

G en de r

Other record-able cases

Remained at work

Using these categories, check ONLY the most serious result for each case:

Sk in

D is or de r

R es pi ra to ry

C on di tio n

Away from work (days)

In ju ry

Death

Job transfer or restriction

Record Of Injuries & Illnesses