Attachment 5 MCSC Mishap Form OSHA form 300 or equivalent.pdf
PDF 406 KB Posted
- Attached to
- ERS COMS-Systems MATOC Amended RFP 0003 Federal contract opportunity
- Solicitation number
- M6785420R7828
- Issued by
- United States Marine Corps
About this file
This solicitation notice seeks proposals for an Indefinite Delivery/Indefinite Quantity Multiple Award Task Order Contract to provide Equipment Related Services Contractor Operator and Maintenance Services for various Marine Corps training systems. The services include sustainment support for training devices such as simulators and simulations systems located at Camp Pendleton, Camp Lejeune, Twenty-Nine Palms, Camp Upshur, Fort Leonard Wood, Cherry Point, Gulfport, Yuma, Marine Corps Base Hawaii, locations in Japan, and worldwide Reserve and shipboard locations. The period of performance is a base period of 60 months plus one 5-year option. The NAICS code is 811310 and size standard is $8 million. Proposals are due by December 7, 2020 and award is expected in the second quarter of fiscal year 2021. The solicitation will result in awards under the Small Business Set-Aside and utilize firm-fixed price and cost reimbursement contract types.
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Text version
MARINE CORPS SYSTEMS COMMAND MISHAP AND NEAR MISS REPORT
TO: Commander, Marine Corps Systems Command
1. INJURED PERSON OR PERSON INVOLVED IN NEAR MISS: (Last Name. First, MIJ
2. AGE: 3. SEX: 4. PAY GRADE: 5. MOS/OCCUPATION/TRADE: 6. TRAINING/CERTIFICATION:
7. COMPONENT: 8. JOB ASSIGNMENT: 9. YEARS OF EXPERIENCE:
10. REPORTING ACTIVITY/UNIT: (Command , Division, etc.) 11. DUTY STATION:
12. CHECK ONE: (Or more, it applicable.)
□ FATALITY 0 INJURY
□ PERMANENT TOTAL □ PERMANENT PARTIAL
DISABILITY DISABILITY
□ OCCUPATIONAL ILLNESS
0 PROPERTY DAMAGE
□ NEAR MISS
13. DATE OF INJURY/INCIDENT: 14. DAY OF WEEK: 15. HOUR OF DAY: 16. DUTY STATUS: (Attimeotmishap.J
17. DATE RETURNED TO WORK: 18. NO. WORKDAYS LOST: 19. NO. LIGHT DUTY DAYS: 20. NO. DAYS HOSPITALIZED:
21. PLACE OF OCCURRENCE: (St , Bldg, Rm, etc.)
ON BASE
□ OFF BASE
22. ASSIGNED WORKPLACE: (Occupational mishaps only)
23. WITNESS: (Name, Address and Telephone Number)
24. DESCRIPTION OF MISHAP/INCIDENT: (Describe circumstances and events [who, what, when, where, why and how} leading to the mishap/near miss in sufficient detail that reviewing authorities may gain a complete understanding of cause and effect relationships. If more space is needed use a blank sheet of paper and attach to this form.)
25. EVENT /EXPOSURE: (Describe "How" injury/near miss occurred, e.g., struck by, fall, etc.)
26. TYPE OF INJURY: (CuV La ceration , Bruise/Contusion, etc.) 27. BODY PART INJURED: (Right Arm, Lett Leg, etc.)
28. WEATHER CONDITION: 29. UNSAFE PERSONAL FACTOR: (Speeding , looked away, etc.)
30. PERSONAL PROTECTIVE EQUIPMENT REQUIRED: 31. PERSONAL PROTECTIVE EQUIPMENT UTILIZED:
32. DOD PROPERTY, EQUIPMENT DAMAGED: 33. NON-DOD PROPERTY, EQUIPMENT DAMAGED:
34. TOTAL COST PROPERTY DAMAGED: 35. TOTAL INJURY COST: (lfknown.J
MCSC Form 510211 (03114) (PAGE 112) PREVIOUS EDITIONS ARE OBSOLETE Command Safety (00T) (03114)
PERSON INVOLVED IN MISHAP SIGN BELOW
SUPERVISOR SIGN BELOW
UNIT SAFETY OFFICER SIGN BELOW
COMMANDING OFFICER/DIVISION DIRECTOR SIGN BELOW
| 1 INJURED PERSON OR PERSON INVOLVED IN NEAR MISS Last Name First MIJ: |
| 2 AGE: |
| 3 SEX: |
| 4 PAY GRADE: |
| 5 MOSOCCUPATIONTRADE: |
| 6 TRAININGCERTIFICATION: |
| 7 COMPONENT: |
| 8 JOB ASSIGNMENT: |
| 9 YEARS OF EXPERIENCE: |
| 10 REPORTING ACTIVITYUNIT Command Division etc: |
| 11 DUTY STATION: |
| 13 DATE OF INJURYINCIDENT: |
| 14 DAY OF WEEK: |
| 15 HOUR OF DAY: |
| 16 DUTY STATUS AttimeotmishapJ: |
| 17 DATE RETURNED TO WORK: |
| 18 NO WORKDAYS LOST: |
| 19 NO LIGHT DUTY DAYS: |
| 20 NO DAYS HOSPITALIZED: |
| 22 ASSIGNED WORKPLACE Occupational mishaps only: |
| 23 WITNESS Name Address and Telephone Number: |
| 24 DESCRIPTION OF MISHAPINCIDENT Describe circumstances and events who what when where why and how leading to the mishapnear miss in sufficient detail that reviewing authorities may gain a complete understanding of cause and effect relationships If more space is needed use a blank sheet of paper and attach to this form: |
| 25 EVENT EXPOSURE Describe How injurynear miss occurred eg struck by fall etc: |
| 26 TYPE OF INJURY CuV La ceration BruiseContusion etc: |
| 27 BODY PART INJURED Right Arm Lett Leg etc: |
| 28 WEATHER CONDITION: |
| 29 UNSAFE PERSONAL FACTOR Speeding looked away etc: |
| 30 PERSONAL PROTECTIVE EQUIPMENT REQUIRED: |
| 31 PERSONAL PROTECTIVE EQUIPMENT UTILIZED: |
| 32 DOD PROPERTY EQUIPMENT DAMAGED: |
| 33 NONDOD PROPERTY EQUIPMENT DAMAGED: |
| 34 TOTAL COST PROPERTY DAMAGED: |
| 35 TOTAL INJURY COST lfknownJ: |
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File details come from the government source that posted it. Updated .