Attachment 6 - Monthly Record of Exposure Hours.pdf
PDF 27 KB Posted
- Attached to
- Garrison Project Admin and OM Janitorial Federal contract opportunity
- Solicitation number
- W9128F24Q0016
About this file
This document contains a monthly record of exposure hours template for reporting work-related injuries and illnesses in accordance with an Army Corps of Engineers contract. The template requires contractors to report monthly exposure hours and record details of any occupational injuries or illnesses occurring during work covered under the contract. For each case, contractors must provide data elements such as employee age and gender, job title, date of injury or illness onset, affected body parts, case classification, days away from work, job transfer or restriction, and contributing factors. Contractors must also submit accident investigation reports using ENG Form 3394 for all recordable cases. The template aims to comply with Corps of Engineers safety program requirements for prime contractors and subcontractors to report monthly exposure and accident experience for work covered under their contracts.
The related federal contract opportunity is a solicitation from the Department of the Army Corps of Engineers Engineering District Omaha for garrison project administration and operations and maintenance janitorial services. No further details are provided on products or services required, response dates, pricing terms, set asides, or incumbent contractors.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Government Responses to Questions_W9128F24Q0016_01.12.2024.pdf | ||
| AM0001_W9128F24Q0016 GA Janitorial.pdf | ||
| Government Responses to Questions_W9128F24Q0016_12.28.2023.pdf | ||
| Attachment 3 - MF Floor Plan.pdf | ||
| RELEASED_W9128F24Q0016 GA Janitorial.pdf | ||
| Attachment 2 - Ad Floor Plan.pdf | ||
| Attachment 4 - Admin Clng Req.pdf | ||
| Attachment 5 - MF Clng Req.pdf |
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Text version
Month Year
City
Describe The Case
(B1) (B2) (B3) (C) (D) (F)
(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
Date of injury or onset of illness
Classify the caseIdentify the person
State
Contract Number
USACE Command
On job transfer or restriction (days)
Away from work (days)
In ju ryOther record-able cases
Project Title
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)
Check the "injury" column or choose one type of illness:
Contractor Name
Certification of Record Name of Person Submit. Record
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.
FUDS
(mo./day)
FUSRAP
IRP
Year to Date
Days away from work
Signature
USACE PRIME CONTRACTOR
Pr im e or
S ub
(P o r S
Company Name
(A)
Ag e
G en de r
(E) Where the event occurred (e.g. Loading dock north end)Date
Employee Began
Work on Job
Covered by
Contract
Job Title (e.g., Welder)
Sk in
D is or de r
R es pi ra to ry
C on di tio n
Po is on in g
H ea rin g
Lo ss
(M)
US Army Corps of Engineers
Job transfer or restriction
Enter the number of days the injured or ill worker was:
Remained at work
Using these categories, check ONLY the most serious result for each case:
Al l o th er
Ill ne ss es
Date
Exposure Hours Month
___ of ___Page
Death
USACE Office Overseeing Work
Ordinance/Expl. Cleanup Environmental Other
For Government Use Only TYPE OF WORK ACTIVITY (Choose One):
Environmental Remed.
Superfund
Record Of Injuries & Illnesses
File details come from the government source that posted it. Updated .