Attachment 5 - F 4.15.4 PRE-PERFORMANCE Data Collection.pdf

F 4.15.4

PRE-PERFORMANCE DATA COLLECTION

Contracting and Executing Comapny Identification

Rev. 21 October 2025

PURPOSE:

• To collect the preliminary data necessary for drafting the DUVRI (Interference Risk Assessment Document), in the cases provided for by Article 26, paragraph 3, of Legislative Decree 81/2008 (TUSSL).

• This form constitutes an integral part of the Interferential Risk Assessment Document (DUVRI).

SCOPE OF APPLICATION

• This form serves as a preliminary assessment tool to determine whether the conditions for drafting the DUVRI are met, while ensuring in all cases the mutual exchange of information between the Client and the Contractor.

• This form applies to all types of work activities, including temporary or mobile construction sites, and to all services, regardless of the method of assignment (contract or direct award with GPC), in relation to the purposes indicated above.

• This form does NOT apply in the case of supplies of goods, materials, or similar items, for which the drafting of the DUVRI is not required. However, the Client remains responsible for verifying the technical and professional suitability of the companies involved (F 4.15.1, F 4.15.2).

DEFINITIONS

• Client (Committente): the entity on whose behalf the work is carried out and who holds decision-making and financial authority. The Client may appoint a Work Supervisor (Responsabile dei Lavori) to act on their behalf.

• Contracting Company (Impresa Affidataria / Appaltatrice): the company holding the contract with the Client. To perform the work or service, it may use subcontractor companies or self-employed workers, and in both cases it is required to verify the safety conditions of the assigned activities, including Technical and Professional Suitability (Annex XVII of Legislative Decree 81/08).

• Executing Company (Impresa Esecutrice): the company that directly performs the work or part of it, using its own personnel and equipment. It may coincide with a subcontractor company.

• Subcontractor Company (Impresa Subappaltatrice): the company to which the Contracting Company assigns the execution of the work or part of it, employing its own personnel and equipment.

INSTRUCTIONS:

• To be completed by the CONTRACTING COMPANY [companies and self-employed workers] o Complete all sections.

o Send the form to 31FW.CCPP.DUVRI@us.af.mil and copy the Contracting Office or the point of contact who requested the work/service.

o Where coordination for the drafting of the DUVRI is required, the company will be contacted again by the 31

FW/CCPP office.

Notes regarding any supporting documentation requested:

o Compressed files (.zip, .rar, etc.) are blocked by the system.

o For files larger than 15 MB, the file transfer portal must be used https://safe.apps.mil/

For clarification:

31 FW/CCPP, Prevention and Protection Office [Safety and Occupational Health – FN requirements, D.Lgs 81/08]

Email: 31FW.CCPP.DUVRI@us.af.mil Comm. +39 0434 307722 Hours: Mon-Fri 8.30-12.30/13.30 -17.30 Aviano Air Base, Bldg. 1472 mailto:31FW.CCPP.DUVRI@us.af.mil https://safe.apps.mil/ mailto:31FW.CCPP.DUVRI@us.af.mil

Contracting and Executing Comapny

TO BE COMPLETED BY CONTRACTING COMPANY (Appaltatrice) INFORMATION NOTICE ON THE PROCESSING OF PERSONAL DATA (EU Regulation 2016/679 – GDPR) - The company data collected will be processed exclusively for institutional purposes and legal obligations, using appropriate methods and within the necessary limits, including through electronic tools. The processing is carried out by the Delegate of the Client’s Employer and performed by authorized personnel. Data subjects are guaranteed the rights provided for in Articles 15–21 of the GDPR.

B. CONTRACTING COMPANY DETAILS

Company Name

Tax Code and VAT Number

Registered Office Address

Telephone Number and E‑mail

ATECO Code

Employer [name, phone, e‑mail] HSE Manager – RSPP (Health and Safety Prevention and Protection Service Manager) [name, phone, e‑mail]

MC – Occupational Physician [name, phone, e‑mail]

RLS / RLS -T, Employees’ Safety Representative

Nominativi Preposti (In loco) [name, phone]

First Aid Appointees On-Site

Fire Safety Responders On-Site Company Representative for the Work [name, phone, e‑mail]

Total Duration of the Work/Service No. Od days Period from/to Number of Workers Involved in the Activity Total no. No. Per day Will the Contracting Company also be the sole Executing Company? ☐ si [compilare solo sezione B] ☐ no [compilare sezioni: B, C per ciascuna ditta] List the EXECUTING COMPANIES and respective assigned tasks Company #1 Work assigned

[provide for each company the info required in Section C] Company #2 Work assigned

Company #3 Work assigned

Company #4 Work assigned

A. WORK DETAILS

Work Identification [Contract number/project and title]

Area and Building subject to work/service [e.g.: Area F, Bldg 1472 LN Safey Office]

Work Area [ e.g.: entrance, warehouse, restrooms, offices …]

Brief Description of the Work [ e.g.: flooring replacement, cleaning services…]

Contracting Office POC [CONS] Technical Office POC [CES]

Contracting and Executing Comapny

C. RISKS GENERATED BY THE EXECUTING COMPANIES

Work phases:

Phase Description Involved Companies Notes

Vehicles and Machinery Used [e.g. trucks, vans, flatbeds, trailers, forklifts, excavators, MEWPs (Mobile Elevating Work Platforms), hoists, tankers, water tankers, concrete mixers, mobile cranes...)

Equipment used [work tools, manual equipment, electrical equipment, ...]

Chemical agents, substances and mixtures used

C. EXECUTING COMPANY / SUBCONTRACTOR DETAILS - #1

Tax Code and VAT Number

Registered Office Address

Telephone Number and E‑mail

ATECO Code

Employer [name, phone, e‑mail] HSE Manager – RSPP (Health and Safety Prevention and Protection Service Manager) [name, phone, e‑mail]

MC – Occupational Physician [name, phone, e‑mail]

RLS / RLS -T, Employees’ Safety Representative

Nominativi Preposti (In loco) [name, phone]

First Aid Appointees On-Site

Fire Safety Responders On-Site Company Representative for the Work [name, phone, e‑mail]

Work assigned to the Company [brief description]

Contracting and Executing Comapny

C. EXECUTING COMPANY / SUBCONTRACTOR DETAILS - #2

Tax Code and VAT Number

Registered Office Address

Telephone Number and E‑mail

ATECO Code

Employer [name, phone, e‑mail] HSE Manager – RSPP (Health and Safety Prevention and Protection Service Manager) [name, phone, e‑mail]

MC – Occupational Physician [name, phone, e‑mail]

RLS / RLS -T, Employees’ Safety Representative

Nominativi Preposti (In loco) [name, phone]

First Aid Appointees On-Site

Fire Safety Responders On-Site Company Representative for the Work [name, phone, e‑mail]

C. EXECUTING COMPANY / SUBCONTRACTOR DETAILS - #3

Tax Code and VAT Number

Registered Office Address

Telephone Number and E‑mail

ATECO Code

Employer [name, phone, e‑mail] HSE Manager – RSPP (Health and Safety Prevention and Protection Service Manager) [name, phone, e‑mail]

MC – Occupational Physician [name, phone, e‑mail]

RLS / RLS -T, Employees’ Safety Representative

Nominativi Preposti (In loco) [name, phone]

First Aid Appointees On-Site

Fire Safety Responders On-Site Company Representative for the Work [name, phone, e‑mail]

C. EXECUTING COMPANY / SUBCONTRACTOR DETAILS - #4

Tax Code and VAT Number

Registered Office Address

Telephone Number and E‑mail

ATECO Code

Employer [name, phone, e‑mail] HSE Manager – RSPP (Health and Safety Prevention and Protection Service Manager) [name, phone, e‑mail]

Contracting and Executing Comapny

MC – Occupational Physician [name, phone, e‑mail]

RLS / RLS -T, Employees’ Safety Representative

Nominativi Preposti (In loco) [name, phone]

First Aid Appointees On-Site

Fire Safety Responders On-Site Company Representative for the Work [name, phone, e‑mail]