B08 AS OFFERED - Appendices.pdf

Appendix I

(Put on Company Letterhead)

QUALITY CONTROL PLAN

W911WN-23-P-3001

Building and Grounds Maintenance Service Berlin Lake

Weston, Ohio

Brief statement describing your company’s management philosophy relative to its commitment to quality.

1. Describe inspection process for each section of the contract.

2. List names of inspectors.

3. Describe process to identify deficiencies in quality of services performed before the level of performance is unacceptable.

4. Describe process for retaining records of inspections and corrective actions taken.

5. Accident Prevention:

a. Policy Statement for accident prevention signed by the Contractor (program and enforcement)

b. Emergency phone numbers

c. Equipment inspections

d. Safety training

e. Personal protective equipment required

Signature of contractor Date: _______________

Approved by: Date: ________________

COR

1. SIGNATURE SHEET.

This Accident Prevention Plan was

Prepared By:

Name Title of corporate safety staff person

Approved By:

Name President

2. BACKGROUND INFORMATION

a. Contractor: Name Address City, State Zip

b. Contract Number W911WN-19-D-3###

c. Project Name: Mahoning Creek Lake

d. Project Description: Building and Grounds Maintenance Service

e. Name of Company’s recent accident history is included as Attachment #__ to this Accident Prevention Plan. Information included includes EMR, OSHA 200 Forms and corporate safety trend analyses.

f. The Major definable features of work are: ______________________________. An Activity Hazard Analysis (AHA) will be prepared for each Major Definable Feature of Work. AHAs will be prepared in accordance with the format shown on page 4 of EM 385-1-1 and will be presented

Appendix II

ACCIDENT PREVENTION PLAN

Solid Waste Removal Services

Berlin Lake, Weston OH

W911WN23P3001

Waste Management of Ohio, Inc.

and discussed at the Preparatory Phase Inspection for the applicable feature of work.

3. STATEMENT OF SAFETY AND HEALTH POLICY

Enter statement which describes the company‘s commitment to safety.

4. RESPONSIBILITIES AND LINES OF AUTHORITIES

a. Name - Describe responsibility and accountability of personnel responsible for safety at corporate level.

b. Name - Describe responsibility and accountability of personnel responsible for safety at project level.

c. Lines of authority - Describe lines of authority (as related to safety) for this project.

5. SUBCONTRACTORS AND SUPPLIERS.

a. The following subcontractors will be working on this project:

1. List

b. The CQC System Manger (if someone else, identify) will be responsible for controlling and coordinating subcontractors and suppliers.

c. All subcontractors and suppliers performing work on site will be expected to conform to the requirements of this Accident Prevention Plan and to the requirements of EM 385-1-1.

6. TRAINING.

a. Each employee will receive a safety indoctrination consisting of a thorough review of applicable AHA’s.

b. The following is a list of mandatory training and certifications which are applicable to this project:

1. Vehicle Operator

2. Personal Protective Equipment)

3. Other

c. The following identifies requirements for periodic retraining or recertification relating to item b above.

1. List

d. The following individuals shall be trained in the contents of the Emergency Response Plan discussed in Section 12 of this Accident Prevention Plan:

1. List

e. Weekly toolbox safety meeting will be conducted at TIME every ENTER DAY OF WEEK.

Each on site worker will be required to attend. Attendance will be documented. Name will be responsible for conducting these meetings.

7. SAFETY AND HEALTH INSPECTIONS.

a. Name will conduct site safety inspections on a daily basis. Any noted deficiencies will be identified on that day’s CQC Report. Deficiencies will be tracked using the table included as Attachment # __ to this Accident Prevention Plan.

b. The following external inspections/certifications are required for this project:

List or enter “None Required”.

8. SAFETY AND HEALTH EXPECTATIONS, INCENTIVE PROGRAMS, AND

COMPLIANCE

a. Provide a statement or statements describing the company's written safety program goals, objectives, and accident experience goals for this contract.

b. Provide a brief description of the company's safety incentive programs (if any). If none, so state.

c. Provide a discussion of the company’s policies and procedures regarding noncompliance with safety requirements (to include disciplinary actions for violation of safety requirements).

d. Provide written company procedures for holding managers and supervisors accountable for safety.

9. ACCIDENT REPORTING

a. Name will submit Monthly Manhour Exposure Reports to the Contracting Officer no later than the 5th work day of each month. The report encompasses on-site work including all hourly and salaried employees. The report will include all subcontractors working on this project.

b. Name will complete the report and submit it to the Contracting Officer within five (5) workdays.

c. Name will immediately notify the Contracting Officer and District Safety Officer of any incidents involving a fatality or permanent total disability, accidents in which three or more persons are hospitalized, accidents that result in property damage in excess of $100,000 or any accident regardless of the consequences, if it is suspected that it will result in unfavorable criticism of the Corps of Engineers..

10. MEDICAL SUPPORT

a. A list of emergency telephone numbers and a map of directions to the nearest hospital(s) is included in the Emergency Response Plan section of this Accident Prevention Plan.

b. First aid kits will be maintained on site as required in Section 3 of EM 385-1-1.

c. At least two employees on each shift will be qualified to administer first aid and CPR.

Individuals who are required to work alone in remote areas shall be trained in first aid. The following employees are certified in First Aid and CPR and a copy of their current certificates are included as Attachment # __ to this Accident Prevention Plan:

1. List

11. PERSONAL PROTECTIVE EQUIPMENT.

a. Outline procedures (who, when, how) for conducting hazard assessments and written certifications for use of personal protective equipment.

12. PLANS (PROGRAMS, PROCEDURES) REQUIRED BY THE SAFETY MANUAL (as applicable)

a. Hazard Communication (HAZCOM) Program (01.B.04)

Included as Attachment # __ to this Accident Prevention Plan is a written hazard communication program addressing as a minimum, the following: training (to include potential safety and health effects from exposure), labeling, current inventory of hazardous chemicals on site, and the location and use of Material Safety Data Sheets (MSDSs).

b. Emergency Response Plans (01.E.01, 01.E.05, 06.A.02, 19.A.04, 09.K.01 and 09.K.02)

An Emergency Response Plan is included as Attachment # __ to this Accident Prevention Plan. This Emergency Response Plan includes:

An Emergency Response Plan to ensure employee safety in case of fire or other emergency.

Emergency telephone numbers and reporting instructions for ambulance, physician, hospital, fire, and police. Also included is a map of directions to the nearest hospital(s). This list and map shall be conspicuously posted at the work site.

c. Respiratory Protection Plan (05.E.01)

Name of Company‘s Respiratory Protection Plan is included as Attachment # __ to this Accident Prevention Plan.

d. Health Hazard Control Program (06.A.02)

Activity Hazard Analyses (AHA’s) shall consider all substances, agents and environments that present a hazard and will recommend hazard control measures. Engineering and administrative controls shall be used to control hazards. In cases where engineering or administrative controls are not feasible, PPE may be used. The AHA shall serve as certification that a hazard assessment has been conducted.

e. Plan for Prevention of Alcohol and Drug Abuse (Defense Federal Acquisition Regulation Supplement Subpart 252.223-7004, Drug-Free Work Force)

Name of Company‘s plan for prevention of Alcohol and Drug Abuse is included as Attachment # __ to the Accident Prevention Plan. This plan meets the minimum requirements of

DFAR 252.223-7004.

13. Detailed site specific hazards and controls will be provided in the activity hazard analysis (AHA) for each phase of the operation (each Major Definable Feature of Work as defined by the Contractor Quality Control Plan). The AHA’s will provide information on how the requirements of major sections of EM 385-1-1 will be met. Particular attention shall be paid to excavations, scaffolding, medical and first aid requirements, sanitation, personal protective equipment, fire prevention, machinery and mechanized equipment, electrical safety, public safety requirements, and chemical, physical agent, and biological occupational exposure prevention requirements.

AHA’s will be prepared utilizing the format shown on page 4 of EM 385-1-1.

Attachments Attachment # - Accident History Attachment # - Safety Deficiency Tracking Table Attachment # - Emergency Response Plan Attachment # - First Aid and CPR certificates Attachment # - Hazard Communication (HAZCOM) Program Attachment # - Emergency Response Plan Attachment # - Plan for Prevention of Alcohol and Drug Abuse

NAME (Last, First Middle) DOB (mm/dd/yyyy) SSN (no dashes)

CUI

Controlled by: USACE Controlled by: CELRP-SM Category: PRVCY Distribution: FED ONLY

POC: See below

CUI

CUI

Primary Contact: Ivan Russell - Security Specialist 412-395-7591 ivan.r.russell@usace.army.mil

Alternate Contact: Andrew Wasko - Security Specialist 412-395-7643 andrew.j.wasko@usace.army.mil

Chief of Security: Joe Bali 412-395-7162 joseph.m.bali@usace.army.mil

Contract Location: Company POC Name:

CUI

Contract Number: Army COR Name:

Please do not send multiple 1-2 person requests in a single day

Appendix III

Appendix IV

Appendix V (For I REPORT NO. I EROC I UNITED ST ATES ARMY CORPS OF ENGINEERS I REQUIREMENT Safety CODE

ACCIDENT INVESTIGATION REPORT CONTROL SYMBOL:

Staff only) /For Use of this Form See Helo Menu and USACE Sunn/ to AR 385-40! CEEC-S-8(R2)

1. ACCIDENT CLASSIFICATION

PERSONNEL CLASSIFICATION INJURY/ILLNESS/FATAL PROPERTY DAMAGE MOTOR VEHICLE INVOLVED DIVING

GOVERNMENT

0 CIVILIAN □ MILITARY □ □

FIRE

□ OTHER □ □ INVOLVED

0 CONTRACTOR □ 0 FIRE

INVOLVED □ OTHER □ □

□ PUBLIC 0 FATAL 0 OTHER

2. PERSONAL DATA

a. Name (Last, First, Ml) b. AGE I

c. SEX d. SOCIAL SECURITY NUMBER l e.GRADE

□ MALE 0 FEMALE

f. JOB SERIES/TITLE g. DUTY STATUS AT TIME OF ACCIDENT h. EMPLOYMENT STATUS AT TIME OF ACCIDENT

□ ARMY ACTIVE □ ARMY RESERVE □ VOLUNTEER

0 ON DUTY □ TDY □ PERMANENT □ FOREIGN NATIONAL □ SEASONAL

□ TEMPORARY □ STUDENT

0 OFF DUTY □ OTHER (Specify)

3. GENERAL INFORMATION

a. DATE OF ACCIDENT b. TIME OF ACCIDENT c. EXACT LOCATION OF ACCIDENT d. CONTRACTOR'S NAME

(month/day/year) (Military time)

(1) PRIME:

hrs

e. CONTRACT NUMBER f. TYPE OF CONTRACT g. HAZARDOUS/TOXIC WASTE

ACTIVITY

CONSTRUCTION SERVICE

□ SUPERFUND □ DERP (2) SUBCONTRACTOR:

□ CIVIL WORKS 0 MILITARY □ A/E □ DREDGE

□ IRP □ OTHER (Specify)

□ OTHER (Specify) □ OTHER (Specify)

4. CONSTRUCTION ACTIVITIES ONLY /Fill in line and corresoondino code number in box from list - see helo menu/

a. CONSTRUCTION ACTIVITY (CODE) b. TYPE OF CONSTRUCTION EQUIPMENT (CODE)

I# I I#

5. INJURY/ILLNESS INFORMATION (Include name on line and corresoondino code number in box for items e f & o - see helo menu

a. SEVERITY OF ILLNESS/INJURY

e. BODY PART AFFECTED

PRIMARY

SECONDARY

f. NATURE OF ILLNESS/INJURY

6.

a. ACTIVITY AT TIME OF ACCIDENT

7.

b. ESTIMATED c. ESTIMATED

(CODE) DAYS LOST DAYS HOSPIT-

I# I

ALIZED

(CODE) g. TYPE AND SOURCE OF INJURY/ILLNESS

I# I

(CODE)

I# I TYPE

(CODE)

I# I

SOURCE

PUBLIC FATALITY /Fill in line and corresoondence code number in box - see helo menu/

I#

!CODE!

I

b. PERSONAL FLOATATION DEVICE USED?

0 YES O NO

MOTOR VEHICLE ACCIDENT

d. ESTIMATED DAYS

RESTRICTED DUTY

(CODE)

I#

(CODE)

I#

□ N/A

I

I

I

a. TYPE OF VEHICLE b. TYPE OF COLLISION c. SEAT BEL TS USED NOT USED NOT AVAILABLE

[I] PICKUP/VAN [I] AUTOMOBILE □ SIDE SWIPE □ HEAD ON 0 REAR END (1) FRONT SEAT

[I] TRUCK [I] OTHER (Specify) □ BROADSIDE □ ROLL OVER □ BACKING

□ OTHER (Specify) (2) REAR SEAT

8. PROPERTY /MATERIAL INVOLVED

a. NAME OF ITEM b. OWNERSHIP c. $ AMOUNT OF DAMAGE

(1)

(2)

(3)

9. VESSEL/FLOATING PLANT ACCIDENT /Fill in line and corresnondence code number in box from list - see heln menu/

a. TYPE OF VESSEL/FLOATING PLANT (CODE) b. TYPE OF COLLISION/MISHAP (CODE)

I# I I#

10. ACCIDENT DESCRIPTION /Use additional oaoer if necessaNI

I

ENG FORM 3394, MAR 99 Version 2 EDITION OF SEP 89 IS OBSOLETE. Page 1 of 4 pages (Proponent: CESO )

Appendix VI

Electronic Invoicing Instructions for the USACE Finance Center

In lieu of submitting a hardcopy invoice to the USACE Finance Center (UFC) in Millington, TN via the United States Postal Service per the contract instructions in Block 18a, you may submit an electronic version via email per the instructions below:

1. Save or scan the invoice so that it is an electronic (pdf) file.

2. Circle the amount to be paid. See Attached Example.

3. File name of the INVOICE must be the obligation number. (ex: W911WN-00-X-0000).

4. Attach the Invoice (see # 3) to an email. Make sure the file name is the obligation number.

5. The subject line of the email should contain only the OBLIGATION number (same as the INVOICE file name)

6. Email the PDF file to: CEFC-H4 Invoices@usace.army.mil and CC your contracting POC as well as the USACE project POC to whom the goods or services were delivered to confirm receipt.

7. You can only submit 1 invoice per email to the UFC. If you need to submit 3 invoices then you must send 3 separate emails.

8. See below for a sample email submission to the UFC.

9. This process does not apply to ENG93 payments; i.e. Progress payments for construction and Architect/Engineer contracts.

Items to Note:

1. Circle the dollar amount to be paid on the invoice

2. If you are sending multiple invoices to the Finance Center, each invoice must be sent down in a separate email. Only 1 invoice per email.

3. The attached invoice’s file name must be the obligation number.

4. The subject of the email to the UFC must also be the obligation number.

5. Email is sent to CEFC-H4 Invoices@usace.army.mil AND

6. CC the USACE contracting POC and the USACE Project POC to whom the goods or services were provided.

7. This new process does not apply to ENG93 payments; i.e. Progress payments for construction and Architect/Engineer contracts.