Attachment 04.pdf

1. Date Prepared: __________________________________ 5. Activity: _____________________________________________

2. Contract Number: __________________________________ _____________________________________________

3. Contract Name: __________________________________ 7. Analysis Phase & Date: _____________________________________________

4. Prepared by: __________________________________ 8. Reviewed By MVK‐SO: _____________________________________________

9. JOB STEPS 10. HAZARDS 11. ACTIONS TO ELIMINATE OR MINIMIZE HAZARDS

12. EQUIPMENT 13. TRAINING 14. INSPECTION

MVK Form 385‐359‐R (Revised) January 2011 Proponent MVK‐SO

Accident Prevention Program

Activity Hazard Analysis

6. Estimated Start Date:

15. SSHO Name & Signature 16. Project Manager/Superintendent Name & Signature

INSTRUCTIONS FOR COMPLETION OF MVK Form 385-359-R

Item Number Instruction

1, 2, & 3 Self-explanatory.

4 The Company representative that prepared the hazard analysis, and title if not given later in the form.

5 Activity refers to the specific phase of work being analyzed, (e.g., clearing & Grubbing, stone placement, form erection. electrical installation, pile driving, etc.).

6 Estimated start date of the activity being analyzed.

If this is the initial Hazard Analysis for this activity, indicate “Initial.” If this is an updated analysis for this activity, indicate “Update.” Hazard Analysis should be reviewed and updated at preparatory inspection if needed. Show date discussed with Government representatives.

8 This is for signature of Vicksburg District Safety Officer after his review of submittal.

9 The principal steps of operation for the activity should be identified in the sequence in which they occur.

10. The hazards associated with each step should be identified.

11 Precautionary actions and controls should be specific to the hazard identified. They should be what the contractor actually intends to implement and enforce, not general comments such as “work will be done in accordance with EM 385-1-1.”

12 All major pieces of equipment that will be used in this activity shall be identified.

13 List any required training already obtained by personnel performing this task, as well as any training that personnel will be taking in order to perform this task safely and efficiently, including equipment operator training.

14 Inspection procedures for equipment identified in item 12 should be stated in this item, as well as training requirements for personnel involved.

15 Name and signature of Contractor’s Site Safety and Health Officer (SSHO).

16 Name and signature of Contractor’s onsite Project Manager or Superintendent.