B08 Exhibit J - PM-12 KTR Accident Reporting Format.xlsx

XLSX spreadsheet 37 KB Posted

Attached to
EAGLE Presidio of Monterey, CA, W519TC-23-R-0104
Solicitation number
W519TC-23-R-0104
Issued by

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This document contains a federal government accident reporting template and details of a related federal contract opportunity. The template outlines required data fields for reporting injuries, property damage, and "mishaps" involving U.S. Army units. It includes dropdown menus and tables to select unit identification codes. The related solicitation is for maintenance, supply and transportation services at the Presidio of Monterey in California. The solicitation number is W519TC-23-R-0104 and is issued by the U.S. Army Contracting Command located at Rock Island Arsenal. The opportunity involves providing logistical support services to units stationed at the specified location. Relevant details include the location of work performance, services required, and issuing agency.

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B08 Attachment 0030 Government Responses to Industry (19MAR2024) -Final.xlsx XLSX spreadsheet
W519TC23R0104-0002_Signed.pdf PDF
W519TC-23-R-0104 Conformed Copy.pdf PDF
W519TC23R0104-0001_SIGNED.pdf PDF
B08 Attachment 0030 Government Responses to Industry (8MAR24) -Final.xlsx XLSX spreadsheet
B08 Attachment 0011 - Contract References Spreadsheet (04MAR24).xlsx XLSX spreadsheet
B08 Attachment 0001 - EAGLE PPI 2.0 PWS POM (07MAR24).pdf PDF
B08 Attachment 0005 - Cost-Price Matrix (POM) (29FEB24).xlsx XLSX spreadsheet
B08 Exhibit B - Contract Data Requirements List (29Feb24) PoM.xlsx XLSX spreadsheet
B08 Exhibit K - SS-01 Supply and Services Report Format updated 19 Jan 24.xlsx XLSX spreadsheet
B08 Attachment 0011 - Contract References Spreadsheet 04JAN2024.xlsx XLSX spreadsheet
B08 Attachment 0013 - Mission Essential EAGLE Contractor Services for Presidio of Monterey.pdf PDF
B08 Attachment 0025 - PWS-Annex D - Environmental Requirements.docx DOCX document
B08 Attachment 0026 - PWS-Annex E Definitions Acronyms and Abbreviations.docx DOCX document
B08 Attachment 0027 - PWS-Annex F - Publications and Forms.docx DOCX document
B08 Attachment 0023 - PWS-Annex B - Supply PRS-PoM (1).docx DOCX document
B08 Attachment 0005 - Cost-Price Matrix (POM).xlsx XLSX spreadsheet
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B08 Attachment 0028 - PWS-Annex G - Government Property Incidental.docx DOCX document
B08 Attachment 0024 - PWS-Annex C - Transportation PRS-PoM (1).docx DOCX document
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Main

Contractor Injury/Mishap Report and/or Property Damage

All Blocks Are RequiredKeyDrop Down MenuAuto Populated
1POC Email Address
2COR Email Address
2/1/243Today's Date
4Mishap Date
5UIC
Enter Valid UIC in Block 56Brigade
Enter Valid UIC in Block 57Battalion
Enter Valid UIC in Block 58LRC
9Where Exactly Did This Accident/Mishap Occur?
10Accident Type
11Accident Context
12Category
13Days in Hospital In-Patient
14Days of Lost Time
15Days of Restricted Work
16Injury/Illness Type
17Cause of Injury
18Body Area
19Specific Body Part
20Attributable Factor
21If Human Error
22What Was Damaged
23Estimated Cost of Damage
24Who/What was Injured/Damaged
What happened
NarrativeWhere did this occur
When did this happen
Why did this happen
25Corrective Actions Taken or Will Take To Prevent This From Happening Again
UIC Table Start
W0DAAAHQ ASCHHCN/A
W0DA6BHQ ASCJPPSO-MAN/A
W0DA4GHQ ASCJPPSO-NWN/A
WJN799401N/AN/A
W0DA49401AFSBn QatarN/A
W0DA51401AFSBn KuwaitN/A
W0DAG7401AFSBn-SWA WEB KuwaitN/A
W0DAH7401AFSBn-AfghanistanN/A
W0DA55401AFSBn SWAN/A
WJN899402N/AN/A
W6XPAA402AFSBn HAWAIIN/A
W6XP01402N/ALRC Hilo (PTA)
W6XSAA402AFSBn ALASKA (LRC JBER)N/A
W6XS01402N/ALRC GREELY
W6XS02402N/ALRC WAINWRIGHT
WJN999403N/AN/A
W6XGAA403N/ALRC Daegu
W6XHAA403AFSBn KoreaN/A
W6XH01403N/ALRC Yongsan
W6XH02403N/ALRC Red Cloud
W6XJAA403N/ALRC Camp Zama
W6XKAA403N/ALRC Torii Station
W0DA52403AFSBn NEAN/A
W0DAC6403AFSBn NEA FWD WEB YOKOHAMAN/A
W0DA53403AFSBn NEA FWD/LST SAGAMIN/A
WJP199404N/AN/A
W6WTAA404N/ALRC Aberdeen Proving Ground (& EA)
W6X8AA404N/ALRC Adelphi
W6WRAA404N/ALRC Detroit Arsenal
W6XCAA404N/ALRC Devens
W6XFAA404N/ALRC Hunter Liggett
W6XRAA404N/ALRC Irwin
W6X9AA404N/ALRC McCoy
W6WVAA404N/ALRC Natick (Soldier Support Center)
W6WUAA404N/ALRC Picatinny Arsenal
W6YFAA404N/ALRC Polk
W6WQAA404N/ALRC Redstone Arsenal
W6WSAA404N/ALRC Rock Island Arsenal
W6XBAA404N/ALRC JB McGuire-Dix
W6YXAA404N/ALRC JB Lewis McChord (JBLM)
W6YX01404N/ALRC Yakima Training Center
W0DA30404AFSBn CHARLESTON (ASLAC)N/A
WJP299405N/AN/A
W6XUAA405N/ABASOPS
W6Y8AA405N/ALRC Ansbach
W6Y0AA405N/ALRC Baumholder
W6Y1AA405N/ALRC Bavaria (Graf)
W6XVAA405N/ALRC Benelux
W6XWAA405N/ALRC Brussels
W6Y3AA405N/ALRC Garmisch
W6Y4AA405N/ALRC Hohenfels
W6Y5AA405N/ALRC Italy (Vicenza)
W6Y6AA405N/ALRC Livorno
W6XZAA405N/ALRC Rheinland Pfalz (Ktown)
W6XXAA405N/ALRC Schinnen
W6XYAA405N/ALRC Stuttgart
W6Y7AA405N/ALRC Wiesbaden
W0DAN5405AFSBn GermanyN/A
W0DAP4405BLSE CAB 12 ID KATTERBN/A
W0DAC9405BLSE SBCT 2ND CR VILSECKN/A
W0DA45405AFSBn AfricaN/A
W0DAB6405LST AfricaN/A
W0DAV8405BLSE 173RD VICENZAN/A
W0DA24405AFSBn Benelux (Eygelshoven)N/A
W0DA8M405APS 2 ZutendaalN/A
W0DA88405APS 2 DulmenN/A
W0DAN6405AFSBn MannheimN/A
WJP399406N/AN/A
W6WXAA406N/ALRC AP Hill
W6WWAA406N/ALRC Belvoir
W6YGAA406N/ALRC Benning
W6X2AA406N/ALRC Carlisle Barracks
W6WYAA406N/ALRC Detrick
W6YHAA406N/ALRC Gordon
W6XAAA406N/ALRC Hamilton
W6YMAA406N/ALRC Jackson
W6YCAA406N/ALRC Lee
W6WZAA406N/ALRC Meade
W6YJAA406N/ALRC Rucker
W6X1AA406N/ALRC West Point
W6YLAA406N/ALRC Hunter Army Airfield
W6YNAA406N/ALRC Joint Base Langley-Eustis
W6X0AA406N/ALRC Joint Base Myer-HH
W6YBAA406AFSBn BraggN/A
W6YDAA406AFSBn CampbellN/A
W6YEAA406AFSBn DrumN/A
W6YKAA406AFSBn StewartN/A
WJP499407N/AN/A
W6XDAA407N/ALRC Buchanan
W6YVAA407N/ALRC Knox
W6YTAA407N/ALRC Leonard Wood
W6X3AA407N/ALRC Leavenworth
W6XEAA407N/ALRC Miami
W6YWAA407N/ALRC Sill
W6YSAA407N/ALRC JB San Antonio
W6YS01407N/ALRC SotoCano
W6X5AA407N/ALRC White Sands Missile Range
W6X4AA407N/ALRC Presidio
W6X6AA407N/ALRC Yuma Proving Ground
W6X7AA407N/ALRC Dugway Proving Ground
W6XQAA407N/ALRC Huachuca
W6YPAA407AFSBn BlissN/A
W6YQAA407AFSBn CarsonN/A
W6YRAA407AFSBn HoodN/A
W6YUAA407AFSBn RileyN/A
UIC Table End
Accident Type Start
Property Damage
Fatality
Injury/Illness That Causes 1 Day Away From Work or More Past Occurance
Injury/Illness That Causes Work Restriction/Job Transfer
Contaminated Needle Stick/Sharp
Work Related Turbuculosis
Medical Treatment Beyond First Aid
Occupational Hearing Loss
First Aid Only
Near Miss
Accident Type End
Accident Context Start
Maintenance
Warehouse
Shop Floor
Dining Facility
Army Tactical Vehicle
Non-Tactical Vehicle
Private Motor Vehicle
Material Handeling Equipment
Pedestrian
Railhead
Watercraft
N/A
Accident Context End
Category Start
Exposure
Vehicular
Other
Caught In/Under/Between-Struck By/Against
Slip/Trip/Fall
Bodily Reaction
Category End
Injury/Illness Type Start
Abrassions
Amputation - No Bone
Amputation - With Bone
Asphyxiation
Burns (Chemical)
Burns (Thermal)
Decompression Sickness (Bends)
Contusion
Concussion
Cuts/Laceration
Dislocation
Fractures
Frostbite
Heat Exhaustion
Heatstroke
Hernia/Rupture
Loss of Consciousness
Noise Injury
Puncture Wound
Rash
Sprains/Strains
Swelling
N/A
Injury/Illness Type End
Cuse of Injury Start
Bodily Reaction
Caught In/Under/Between
Exposure
External Contact
Fell From Elevation
Fell From Same Level
Ingested
Inhaled
Occupational Illness/Injury
Overexertion
Rubbed/Abbraded
Struck Against
Struck By
Thrown From
N/A
Cause of Injury End
Body Area Start
AreaBodyHeadNeckUpperTrunkLowerN/A
BodyGeneralGeneralGeneralGeneralGeneralGeneralN/A
HeadEar(s)ThroatShoulder(s)ChestHip(s)
NeckEye(s)Arm(s)HeartThigh(s)
UpperFaceElbow(s)AbdominalLeg(s)
TrunkForeheadWrist(s)BackKnee(s)
LowerGeneralHand(s)Shin(s)
N/AJawFinger(s)Calve(s)
NoseAnkle(s)
Foot/Feet
Toe(s)
Body Area End
Attributable Factor Start
FactEnvironmentalMaterielHumanErrorN/A
EnvironmentalN/AN/AComplacencyN/A
MaterielOver-Confident
HumanErrorUnsupervised
N/AUndisciplined
Untrained
Attributable Factor End
GFE/GFF Start
Government Furnished Equipment
Government Furnished Facility
Other
N/A

GFE/GFF End

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