J-0200000-05 Attachment Contractor Safety Self-Evaluation Checklist 08-05-22.xlsx

XLSX spreadsheet 72 KB Posted Jul 31, 2023

Attached to: Maintenance and Repair of Railroad Trackage at Naval Weapon Station Earle, Colts Neck, New Jersey and Other Areas of Responsibility
Solicitation number: N4008523R2526
Issued by: Department of the Navy Naval Facilities Engineering Command

About this file

Written by GovTribe AI · Dec 20, 2023

This document contains templates and instructions for a contractor to complete when invoicing under a federal construction contract. The templates include a Schedule of Prices, Estimate for Voucher, Retentions Summary, and Contractor's Invoice. Detailed instructions are provided for contractors to input cost and pricing information into password-protected cells on each template. Contractors must complete the Schedule of Prices first to populate data on the other templates, which calculate totals, percentages and amounts automatically based on input values. Signatures and certifications are required from authorized contractor representatives on the final invoice. Thorough guidance is given on proper completion and submission of the templates and invoice to ensure accurate payment under the terms of the construction contract.

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Instructions

INSTRUCTIONS FOR COMPLETING
SCHEDULE OF PRICES, ESTIMATE FOR VOUCHER, RETENTIONS SUMMARY, AND CONTRACTOR'S INVOICE
1.	Print out these instructions first, then follow them in completing the worksheets.
Schedule of Prices
2.	The Schedule of Prices worksheet is password-protected. Cells shaded light yellow are for Contractor's input. All other cells (unshaded) are protected against modification.
3.	Click on the Schedule of Prices worksheet tab to begin.
4.	Complete blocks no. 1, 2, and 3 in PART I.
5.	Block no. 1, the ACTIVITY AND LOCATION, should indicate the actual Navy or other Government agency which will ultimately use the construction. Generally, the appropriate agency name can be found in the main contract title. For instance, "Naval Station Pearl Harbor", "Naval Shipyard Pearl Harbor", "Fleet Industrial Supply Center Pearl Harbor", etc.
6.	Block no. 2, the TITLE OF CONTRACT AND SITE LOCATION is self-explanatory and can be easily identified from the contract plans or specification documents.
7.	Block no. 3, the NAME AND ADDRESS OF CONTRACTOR, is also self-explanatory.
8.	A company official (one who can commit the contractor financially and legally) shall sign the Schedule of Prices in Block no. 4. Indicate the signer's title or position as well.
9.	Do not complete blocks no. 1 thru 11 in PART II.
10.	Remember these basic "rules":
	a. If you wish to be paid for your bond premiums separately, identify it as a separate line item and indicate the actual cost of the bond premium unburdened by profit, overhead, taxes, etc.
	b. If you wish to be paid for materials delivered to the site or at another secured location, discuss this with the Contracting Officer first. On nearly all Government contracts, permission to be paid for materials only (when not yet physically incorporated into the construction) can be granted, but only at the sole discretion of the Contracting Officer. If you obtained approval to invoice for materials only, you should separately list these in the Schedule of Prices unburdened by profit, overhead, etc.; however, sales taxes and delivery charges can be included. Often, the amount you "schedule" will not reflect the final total of your material "invoices". If your schedule exceeds invoice totals, the remainder can not be paid until final payment. If your schedule is less than invoice totals, only the scheduled amount will be paid. If you wish to correct these at any time, submit a revised Schedule of Prices for approval.
	c. Avoid using the quantity unit "LUMP SUM", "ONE JOB", or any other singular quantity unit. If you include such line items, you may not request partial payment for that item. Singular quantity items will be paid for when that item is 100% compete.
	d. For scheduled items, use quantities and units that enable the Government Construction Representative to physically measure progress such as "LINEAR METERS", "CUBIC METERS", etc. This will allow for actual measuring of work quantities in place which in turn will permit your obtaining progress payments for partial completions.
	e. It is not necessary to revise your Schedule of Prices whenever a contract modification is issued.
11.	Indicate line item numbers in block 12a using any convention you are comfortable with. Some firms will indicate spec section numbers in the line item number identification. Others use a simple 1-2-3 sequence.
12.	Provide a brief description of the work in block 12b for each item. Keep it concise, preferably not exceeding one line's space.
13.	Indicate field-measurable quantities in block 12c. You may approximate these quantities and round them as you feel necessary. Avoid extreme precision such as hundredths of a foot, etc. Identify the quantity unit such as "M", "M3", "EA", etc.
14.	Identify material unit cost and labor unit cost in blocks no. 12d and 12e respectively. You may use any degree of precision you see fit. The total material COST, total labor COST, and TOTAL COST for each line item will be computed automatically. These computations will round-off to the nearest whole number automatically as well.
15.	The worksheet will automatically provide totals at the bottom of the sheet.
16.	If you need more than one page (this is common-place), request continuation sheets from the Contracting Officer. You will not be able to expand the spreadsheet you have because it is password-protected.
Estimate for Voucher
17.	The Estimate for Voucher worksheet is password-protected. Cells shaded light yellow are for Contractor's input. All other cells (unshaded) are protected against modification. You must complete the Schedule of Prices before you work on the Estimate for Voucher.
18.	Click on the Estimate for Voucher worksheet tab to begin.
19.	Provide the date for which the invoicing period ends.
20.	In the Work-In-Place columns, provide the previous report WIP percentage and the this report (current) WIP percentage. The to date (total) WIP percentage will be automatically computed. Also, the total dollar-value of WIP will be automatically computed and carried over onto your invoice worksheet.
21.	In the appropriate yellow boxes, indicate the modification ID numbers through which the invoice considers. For instance if 8 mods have been incorporated, input "1" and "8" in the boxes.
22.	Indicate the total amount you are withholding (retention) from your subcontractors and suppliers. You must summarize your retentions in the Retentions Summary worksheet. Indicate the amount of previous invoices in the appropriate yellow box near the bottom of the form. Please use the amount you previously invoiced, not the amount you were paid subject to Government-held retentions and adjustments.
23.	If you need more than one page (this is common-place), request continuation sheets from the Contracting Officer. You will not be able to expand the spreadsheet you have because it is password-protected.
Retentions Summary
24.	The Retentions Summary worksheet is password-protected. Cells shaded light yellow are for Contractor's input. All other cells (unshaded) are protected against modification. This sheet does not rely upon completion of other worksheets. You must complete the Schedule of Prices before you work on the Contractor's Invoice.
25.	Click on the Retentions Summary worksheet tab to begin.
26.	List individual subcontractors and suppliers from whom you are withholding payment retentions.
27.	Indicate the amount of each subcontractor's or supplier's invoice and the amount being retained. The retentions total will be carried over automatically onto your invoice worksheet.
28.	Provide brief narrative reason for each retention (e.g. "Late payrolls", "Subcontract agreement", "Purchase Order agreement", etc.).
Contractor's Invoice
29.	The Contractor's Invoice worksheet is password-protected. Cells shaded light yellow are for Contractor's input. All other cells (unshaded) are protected against modification. You must complete the Schedule of Prices before you work on the Contractor's Invoice.
30.	Click on the Contractor's Invoice worksheet tab to begin.
31.	Provide the date of the invoice.
32.	Provide the invoice number (MUST be sequential).
33.	Some data will be automatically shown from the completed Schedule of Prices and Estimate for Voucher, and Retentions Summary worksheets.
34.	Do NOT manually erase, use "white-out", or otherwise manually correct any entries from a hard-copy printout of the Invoice. If manual corrections become necessary, simply draw a single line through the entry and have the authorized Contractor employee initial (acknowledge) the correction.
35.	Provide the title of your company official signing the invoice. This person must be a company owner, corporate officer, or someone authorized to sign the invoice on behalf of the Contractor.
36.	Provide the name and title of your company official certifying the invoice pursuant to contract clause FAR 52.232-5. This person must be a company owner, corporate officer, or someone authorized to certify the invoice on behalf of the Contractor.
37.	Provide the name of your QC Manager certifying the payment pursuant to contract specification section 01200. This person must be the project QC Manager.
38.	Print out the invoice form and have it signed by an authorized Contractor employee.
39.	GOOD LUCK! If you have any questions, please contact your Contracting Officer!

Schedule of Prices

SCHEDULE OF PRICES (CONSTRUCTION CONTRACT)

PART I (To be completed by contractor)
1. ACTIVITY AND LOCATION
	NAVFAC HI, FEAD
2. TITLE OF CONTRACT AND SITE LOCATION
	TO #0013, KOKE'E MV GROUNDING SYSTEM KOKE'E SITE,PMRF, BARKING SANDS, KAUAI, HAWAII
3. NAME AND ADDRESS OF CONTRACTOR
	Su-Mo/Nan JV, 2688 Kilihau St Bay C, HONOLULU, HAWAII 96819
4. SIGNATURE AND TITLE OF CONTRACTOR'S AGENT

PART II (To be completed by ROICC)
1. CONTRACT NO.	2. DATE OF CONTRACT	3. CONTRACT PRICE	4. 2ND LOW BID	5. HIGH BID
N62478-07-D-4007 TO 0013
7. ALLOTMENT OR ALLOCATION NO.	8. APPROPRIATION TITLE			6. NO. OF BIDDERS

9. TIME FOR COMPLETION (Days) 10. REVIEWED BY DATE 11. APPROVED BY DATE

12a. ITEM NO.	12b. DESCRIPTION OF ITEM	12c. QUANTITIES		12d. MATERIAL COST		12e. LABOR COST		12f. TOTAL COST
		NO. OF UNITS	UNIT	UNIT COST	COST	UNIT COST	COST
	Switching Station
1	Site	1	EA	33454	33,454	33454	33,454	66,908
2	Distribution	1	EA	21302	34,783	104351	104,351	139,134
3	Apparatus	1	EA	196773	196,773	65591	65,591	262,364
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
	TOTAL				265,010		203,396	468,406

&6SHEET &10 &"Courier New,Bold"&P&"Arial,Regular"&6 OF &10 &N &"Arial,Bold"&6&F, &A

Estimate for Voucher

ESTIMATE FOR VOUCHER

CONTRACT NO.		ACTIVITY AND LOCATION							CURRENT CONTRACT AMOUNT
N62478-07-D-4007 TO 0013		NAVFAC HI, FEAD							468,406
INSPECTOR		CHECKED BY				APPROVED BY			PERIOD ENDING
									24 May 10
FROM SCHEDULE OF PRICES				% WORK IN PLACE			TOTAL SCHEDULE COST		TOTAL AMOUNT DUE TO DATE
NO.	ITEM	SCHED QTY	UNIT	PREV REPT	THS REPT	TO DATE	FURNISH	INSTALL
	BASIC CONTRACT

1	Site	1	EA	0%	85%	85%	33,454	33,454	56,872
2	Distribution	1	EA	0%	85%	85%	34,783	104,351	118,264
3	Apparatus	1	EA	0%	85%	85%	196,773	65,591	223,009
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
	BASE CONTRACT TOTAL						265,010	203,396	398,145.00
			GROSS AMOUNT DUE TO DATE INCLUDING MODIFICATIONS		THRU				- 0
(This section for Government use only).
% CONTRACT COMPLETED		85.00%						LESS RETENTIONS (See Retentions Summary)	ERROR:#REF!
								SUBTOTAL	ERROR:#REF!
PAYMENT NO.		1						LESS PREVIOUS INVOICED AMOUNT	- 0
								NET AMOUNT THIS VOUCHER	ERROR:#REF!

&"Arial,Bold"&9 &"Arial,Bold"&6&F, &A

CSSA

CONTRACTOR SAFETY SELF-EVALUATION CHECKLIST (MIDLANT) FINAL OVERALL SCORE:

PWD / ROICC / FSC OFFICE:						DATE:
CONTRACTOR:
CONTR. NO.
CONTR. TITLE:
SUPERINTENDENT:					CHECKLIST INSPECTOR:	TOT MONTHLY MAN-HOURS:
SSHO:					QC MANAGER:	TOT CUMULATIVE MAN-HOURS:
Contractor instructions:			For each line item, enter an "X" in a cell, under EITHER the YES or NO columns. The N/As are automatic. Use the arrow keys to navigate.			PROJECT % ==>>> COMPLETE:
IT#	YES	NO
PREPARATORY PHASE / ORM PLANNING
1			N/A	IS AN ACCEPTED ACCIDENT PREVENTION PLAN (APP), OR ABBREVIATED APP, ON-SITE AND UPDATED TO REFLECT CURRENT MANAGEMENT?
2			N/A	IS APPLICABLE UFGS 013526 AVAILABLE IN SITE ?

3 N/A IS A COMPETENT PERSON, EMPLOYED FULL-TIME, AS SITE SAFETY AND HEALTH OFFICER (SSHO) UNLESS SPECIFIED DIFFERENTLY IN THE CONTRACT ?

4 N/A IS THE SSHO ON-SITE AT ALL TIMES WHILE WORK IS BEING PERFORMED ?

5 N/A ARE SAFETY INSPECTIONS/AUDITS, OF THE WORK SITE, MATERIAL, AND EQUIPMENT, CONDUCTED BY A COMPETENT PERSON, DOCUMENTED IN WRITING AND AVAILABLE UPON REQUEST?

6 N/A IS THE SAFETY AND HEALTH BULLETIN BOARD ERECTED IN A COMMON AREA AND IN CLEAR VIEW OF THE ON-SITE WORKERS?

7 N/A IS THE SAFETY AND OCCUPATIONAL HEALTH DEFICIENCY TRACKING SYSTEM ESTABLISHED AND UPDATED DAILY? (REFER TO EM 385-1-1,SEC. 01.A.12.d)

8 N/A IS A QUALIFIED PERSON CONDUCTING AND DOCUMENTING ALL TRAINING AND MEETINGS, INCLUDING THE INDOCTRINATION OF NEW EMPLOYEES?

9	N/A	IS THERE AN ACTIVITY HAZARD ANALYSIS (AHA), WITH A COMPETENT PERSON DESIGNATED AND PROOF OF HIS QUALIFICATIONS ATTACHED, WHICH HAS BEEN ACCEPTED BY THE GOVERNMENT DESIGNATED AUTHORITY (GDA), FOR EACH WORK ACTIVITY ON SITE?
10	N/A	WORK HAS NOT STARTED UNTIL THE AHA IS REVIEWED BY CONTRACTOR, SUBCONTRACTOR(S) AND GOVERNMENT ON-SITE REPRESENTATIVES DURING PREPARATION AND INITIAL PHASE MEETING.

11 N/A ARE WEEKLY SAFETY MEETINGS HELD THAT DOCUMENT ALL WORKERS REVIEW PAST ACTIVITES, PLAN FOR NEW OR CHANGED OPERATIONS, REVIEW AHAs BY TRADE, ESTABLISH SAFE WORKING PROCEDURES FOR UPCOMING HAZARDS, AND PROVIDE SAFETY AND HEALTH TRAINING ?

12 N/A ARE REQUIRED MONTHLY SAFETY MEETINGS HELD WHICH DOCUMENT THAT SUPERVISORS REVIEW PAST ACTIVITES, PLAN FOR NEW OR CHANGED OPERATIONS, REVIEW AHAs BY TRADE, ESTABLISH SAFE WORKING PROCEDURES FOR UPCOMING HAZARDS AND PROVIDE SAFETY AND HEALTH TRAINING?

13	N/A	HAS THE WRITTEN HAZARD COMMUNICATION PROGRAM BEEN SUBMITTED AND IMPLEMENTED IAW 29 CFR 1910.1200 or 29 CFR 1926.59?
14	N/A	IS AN MSDS FOR EACH HAZARDOUS SUBSTANCE MAINTAINED, WITH SITE MAP ATTACHED?

15 N/A DOES THE PRIME CONTRACTOR ASSURE SUBCONTRACTOR COMPLIANCE WITH REQUIREMENTS OF EM-385-1-1?

N/A OTHER? EXTRA CREDIT?

	0	0	0
OFFICE TRAILER / SIGNAGE / GENERAL
16			N/A	ARE OFFICE AND STORAGE TRAILERS ANCHORED?

17 N/A ARE EMERGENCY PHONE NUMBERS POSTED?

18 N/A IS TEMPORARY PROJECT FENCING IN PLACE WHICH EXTENDS FROM GRADE LEVEL TO AT LEAST 48 INCHES IN HEIGHT ABOVE GRADE? (UNLESS GDA DETERMINES OTHERWISE BASED ON RISK ANALYSIS)

19	N/A	ARE SIGNS POSTED ON THE FENCING, EVERY 150 FEET, THAT WARN OF CONSTRUCTION HAZARDS AND REQUIRE THAT UNAUTHORIZED PERSONS KEEP OUT?
20	N/A	IS THE CONTRACTOR, AND HIS SUBS, AWARE OF THE REQUIREMENT TO IMMEDIATELY NOTIFY PWD/ROICC/OICC/FSC OFFICES OF ANY AND ALL INJURIES?
21	N/A	HAVE EMERGENCY PLANS, IN CASE OF FIRE OR OTHER EMERGENCY, BEEN PREPARED IN WRITING AND REVIEWED BY STAFF AND WORKERS?

22 N/A IS DRINKING WATER READILY AVAILABLE WITH DISPOSABLE CUPS AND WASTE RECEPTACLE?

23 N/A ARE TOILETS WITH WASHING FACILITIES AVAILABLE?

24	N/A	IS THERE A READILY-VISIBLE MAP POSTED ON THE SAFETY BULLETIN BOARD WHICH CLEARLY SHOWS THE BEST ROUTE TO NEAREST MEDICAL FACILITY?
25	N/A	IS A 16 UNIT FIRST-AID KIT, TYPE III, AND A POCKET MOUTH PIECE, OR CPR BARRIER, AVAILABLE AND MAINTAINED, WITH INVENTORY LOG?

26 N/A ARE ALL EMPLOYEES WEARING, AS A MINIMUM, A SHORT-SLEEVED SHIRT, LONG PANTS, LEATHER BOOTS OR OTHER PROTECTIVE WORK SHOES?

27	N/A	ARE ALL FLOORS, WORKING SPACES AND PASSAGEWAYS FREE OF PROTRUDING NAILS, SPLINTERS, LOOSE BOARDS, DEBRIS AND UNNECESSARY HOLES OR OPENINGS?
28	N/A	ARE HOUSEKEEPING INSPECTIONS CONDUCTED DAILY AND DOCUMENTED ON SAFETY INSPECTION REPORT?

29 N/A IS TRAFFIC CONTROL AROUND THE WORKSITE ADEQUATE?

N/A OTHER? EXTRA CREDIT?

	0	0	0
FIRE PREVENTION
30			N/A	IS THERE A WRITTEN FIRE PREVENTION PLAN ON SITE AND IS IT USED TO BRIEF EMPLOYEES?

31 N/A ARE FIRE EXTINGUISHERS AVAILABLE, FULLY CHARGED, READILY VISIBLE AND WITHIN 75 FEET FOR LOW HAZARD AREAS?

32 N/A ARE FIRE EXTINGUISHERS INSPECTED MONTHLY, RECORDED ON TAGS, AND INITIALED?

33 N/A IS YOUR FUEL STORED IN SAFETY CANS, LABELED/LISTED, PAINTED RED WITH A YELLOW BAND AND CONTENTS INDICATED?

34 N/A ARE HOT WORK PERMITS OBTAINED FOR WELDING, CUTTING OR OPERATING OTHER FLAME OR SPARK-PRODUCING DEVICES?

35 N/A ARE FIRE WATCHES PROVIDED AS NECESSARY?

N/A OTHER? EXTRA CREDIT?

	0	0	0
PPE
36			N/A	HAS EMPLOYER DOCUMENTED EMPLOYEE AKNOWLEDGEMENT OF PPE TRAINING INCLUDING EMPLOYEE NAME, DATE OF TRAINING, AND SUBJECT MATTER?

37 N/A ARE WORKERS WEARING SAFETY-TOED LEATHER SHOES OR BOOTS MEETING ASTM F 2412 - 05 AND F 2413 - 05 ?

38 N/A ARE HARD HATS BEING WORN PROPERLY AND DO THEY MEET ANSI Z89.1?

39 N/A ARE WORKERS INVOLVED IN ACTIVITIES THAT EXPOSE HANDS TO INJURY USING HAND PROTECTION APPROPRIATE FOR THE HAZARD?

40 N/A ARE SAFETY GLASSES USED WHERE APPROPRIATE?

41 N/A IS HEARING PROTECTION USED WHERE APPROPRIATE? IF YOU NEED TO YELL TO CONVERSE, HEARING PROTECTION IS REQUIRED.

42 N/A DO WORKERS WEAR RESPIRATORS WHERE APPROPRIATE?

43 N/A IS IMPALEMENT PROTECTION PROVIDED WHERE PERSONNEL COULD WORK ABOVE AN IMPALEMENT HAZARD SUCH AS REBAR?

44 N/A ARE PROTECTIVE LEG CHAPS WORN BY WORKERS WHO OPERATE CHAIN SAWS?

45 N/A IS HIGH-VISIBILITY APPAREL BEING WORN WHERE WORKERS ARE EXPOSED TO VEHICULAR OR EQUIPMENT TRAFFIC OF UP TO 45 MPH, WHERE VISIBILITY IS LIMITED OR REDUCED AROUND MOBILE/HEAVY EQUIPMENT AND WHERE THERE ARE NO EFFECTIVE PROTECTIVE TRAFFIC BARRIERS?

N/A OTHER? EXTRA CREDIT?

	0	0	0
SCAFFOLD SAFETY
46			N/A	HAS A SITE-SPECIFIC FALL PROTECTION AND PREVENTION PLAN AND AN AHA BEEN ACCEPTED BY THE GDA PRIOR TO COMMENCING WORK IN ELEVATED AREAS?

47 N/A IS THE ERECTION, MOVING, DISMANTLING, OR ALTERING OF SCAFFOLD SYSTEMS PERFORMED UNDER THE DIRECTION OF A COMPETENT PERSON?

48 N/A IS THE COMPETENT PERSON USING A COLOR-CODED TAGGING SYSTEM? (GREEN = INSPECTED AND SAFE TO USE) ( RED = SCAFFOLD IS NOT SAFE TO USE)

49 N/A ARE SCAFFOLD PLANKS OVERLAPPED NOT LESS THAN 6", NOR MORE THAN 12", OVER END SUPPORTS WITH TOE BOARDS IN PLACE?

50 N/A IS THE SCAFFOLDING PROPERLY PINNED AND ARE ALL CROSS BRACES IN PLACE?

51 N/A IS THE SCAFFOLD HEIGHT 4 TIMES THE SMALLEST BASE DIMENSION AND IS SYSTEM IS SECURED TO THE STRUCTURE?

52 N/A ARE ALL GUARDRAILS IN PLACE?

53 N/A IS THERE A FULL WORK PLATFORM OR DECK AT EACH WORKING LEVEL , WITH NO CRACKS/SPLITS?

54 N/A IS THE WORK PLATFORM OR DECK SECURELY FASTENED TO THE SCAFFOLD?

55 N/A IS THERE SAFE ACCESS PROVIDED TO EACH WORKING LEVEL?

56 N/A IS THE SCAFFOLD SYSTEM PLUMB AND LEVEL?

57 N/A DO SUSPENDED SCAFFOLD SYSTEMS USE AN INDEPENDENT PERSONAL FALL ARREST SYSTEM?

58 N/A ARE PERSONNEL PROHIBITED FROM RIDING ON MANUALLY PROPELLED SCAFFOLDS?

N/A OTHER? EXTRA CREDIT?

	0	0	0
FALL PROTECTION
59			N/A	HAS A SITE-SPECIFIC FALL PROTECTION AND PREVENTION PLAN BEEN ACCEPTED, AND INCLUDED IN THE APP, FOR ALL PERSONNEL USING FALL PROTECTION EQUIPMENT WHO ARE WORKING AT HEIGHTS OR OTHERWISE EXPOSED TO FALL HAZARDS?

60 N/A ARE WORKERS WITH FALL PROTECTION EQUIPMENT USING THE "BUDDY SYSTEM" TO BEGIN THE RESCUE OF A FALLEN WORKER , IF REQUIRED?

61 N/A ARE ALL EMPLOYEES WORKING ABOVE A 6' HEIGHT PROTECTED FROM FALLING TO LOWER LEVEL?

62 N/A ARE EMPLOYEES PROPERLY TRAINED FOR THE FALL PROTECTION SYSTEMS IN USE?

63 N/A HAS THE CONTRACTOR DESIGNATED A COMPETENT PERSON FOR FALL PROTECTION?

64 N/A IS A WRITTEN RESCUE PLAN (IAW ANSI Z359.2) PREPARED AND MAINTAINED WHEN WORKERS ARE WORKING AT HEIGHTS?

65 N/A ARE FULL-BODY HARNESSES BEING USED?

66 N/A ARE ALL WORKERS ALOFT TIED OFF, AT ALL TIMES (100%), TO A STRUCTURAL ELEMENT CAPABLE OF SUPPORTING 5,000 LBS ?

67 N/A HAVE STANDARD GUARDRAILS BEEN PROVIDED WHERE NEEDED?

68 N/A ARE WORK AREAS HIGHER THAN 20 FEET PROVIDED WITH A STAIR ACCESS SYSTEM?

69 N/A HAVE HORIZONTAL LIFE LINES, IF USED, BEEN DESIGNED AND INSTALLED UNDER THE SUPERVISION OF A QUALIFIED PERSON?

N/A OTHER? EXTRA CREDIT?

	0	0	0
LADDER SAFETY
70			N/A	DO LADDERS EXTEND 3' ABOVE A LANDING PLATFORM AND ARE THEY SECURED TO THE STRUCTURE?

71 N/A ARE LADDERS USED WITH HAND TOOLS ONLY?

72 N/A ARE LADDER BASE DISTANCES FROM THE STRUCTURE 1/4 THE LADDER 'S HEIGHT?

73 N/A ALL FLOOR OPENINGS COVERED OR SURROUNDED BY A GUARDRAIL?

74 N/A DO ELECTRICIANS USE NON-CONDUCTIVE LADDERS?

75 N/A ARE STAIRWAYS WITH GUARDRAILS PROVIDED, DURING CONSTRUCTION, FOR ALL STRUCTURES OVER 20' HIGH?

76 N/A DO ALL STAIRWAYS, WITH 4 OR MORE RISERS, HAVE STANDARD STAIR HANDRAILS?

77 N/A CONCUR THAT PORTABLE STEP LADDERS OF OVER 20' ARE NOT USED?

78	N/A	CONCUR THAT LADDERS ARE PROPERLY USED?
	N/A	OTHER? EXTRA CREDIT?

	0	0	0
EXCAVATIONS
79			N/A	HAS AN EXCAVATION/TRENCHING PLAN BEEN SUBMITTED TO, AND ACCEPTED BY, THE GDA, BEFORE STARTING WORK? (EM385-1-1, sec. 25.A.01 a-n)

80	N/A	IS THERE A COMPETENT PERSON PRESENT WITH THE TRAINING, EXPERIENCE AND KNOWLEDGE OF SOIL ANALYSIS, OF PROTECTIVE SYSTEMS, OF 29 CFR 1926, SUB-PART P, AND WHO HAS THE AUTHORITY TO STOP WORK WHEN REQUIRED?
81	N/A	HAS A COMPETENT PERSON INSPECTED AND DOCUMENTED THE EXCAVATION DAILY?

82 N/A IS HIGH-VISIBILITY APPAREL BEING WORN BY ALL WORKERS EXPOSED TO VEHICULAR TRAFFIC OR MOVING EQUIPMENT?

83 N/A DO HYDRAULIC EXCAVATORS, WHEEL/TRACK/BACKHOE LOADERS, WHICH ARE USED TO TRANSPORT OR HOIST LOADS WITH RIGGING, COMPLY WITH EM 385 SEC. 16.S AND HAVE AN AHA SPECIFIC TO THESE OPERATIONS?

84 N/A IS THERE WRITTEN PROOF OF THE QUALIFICATIONS OF EQUIPMENT OPERATORS AND RIGGERS WHO ARE INVOLVED IN HOISTING OR TRANSPORTING OPERATIONS?

85 N/A ARE OPERATIONAL TESTS OF WHE PERFORMED PER EM385-1-1, SEC. 16.F?

86 N/A IS THE MANUFACTURER'S OPERATERS MANUAL ABOARD THE EQUIPMENT?

87 N/A IS THE RIGGING, INCLUDING POSITIVE LATCHING DEVICES, BEING USED PROPERLY?

88 N/A HAS THE RIGGING BEEN INSPECTED?

89 N/A IS THE SWING RADIUS OF EQUIPMENT AND LOAD BARRICADED?

90 N/A DO EXCAVATIONS OVER 4' DEPTH HAVE A LADDER WITHIN 25' AND TWO MEANS OF EGRESS?

91 N/A HAS A PROPER SLOPE, TRENCH BOX OR SHORING BEEN PROVIDED?

92 N/A HAS GROUNDWATER BEEN CONTROLLED OR REMOVED?

93 N/A IS EXCAVATED MATERIAL PLACED AT LEAST 2' BACK FROM TRENCH EDGE?

94 N/A HAS SAFE ACCESS/PROTECTION BEEN PROVIDED TO PREVENT PERSONNEL, VEHICLES, AND EQUIPMENT FROM FALLING INTO EXCAVATIONS?

95 N/A HAS PERIMETER PROTECTION, THAT MEETS CLASS I, II OR III REQUIREMENTS, BEEN PROVIDED?

96 N/A WHERE KNOWN OR SUSPECTED CONTAMINATION IS PRESENT, IS EXCAVATION ATMOSPHERE MONITORED?

N/A OTHER? EXTRA CREDIT?

	0	0	0
ELECTRICAL
97			N/A	HAS A SKETCH OF TEMPORARY POWER DISTRIBUTION SYSTEMS BEEN SUBMITTED /ACCEPTED BY GDA?

98 N/A IS ELECTRICAL WORK BEING PERFORMED BY QUALIFIED PERSONNEL WITH VERIFIABLE CREDENTIALS?

99 N/A HAS AN ENERGIZED WORK PERMIT BEEN SUBMITTED TO GDA PRIOR TO ANY WORK ON ENERGIZED LINES OR EQUIPMENT? (NFPA 70E AND EM385-1-1, SEC 11.A.02.C.1-8)

100 N/A HAVE ARC FLASH REQUIREMENTS BEEN IDENTIFIED AND IMPLEMENTED?

101 N/A ARE PROTECTIVE/TEMPORARY GROUNDS CONNECTED AT EQUIPMENT BEING WORKED ON?

102 N/A ARE TEMPORARY POWER PANELS AND RECEPTACLES PROTECTED FROM WEATHER?

103 N/A ARE GFCI'S IN USE FOR SITE TOOLS ? THIS ALSO APPLIES TO EXISTING OUTLETS IN RENOVATION PROJECTS.

104 N/A ARE TEMPORARY LIGHTS PROPERLY INSULATED FROM SUPPORTS, WITH ALL LAMPS WORKING AND GUARDED?

105 N/A WHEN OVERHEAD POWER LINES ARE IN THE AREA, ARE OPERATIONS PROHIBITED UNLESS MAINTAINING AT LEAST 10' DISTANCE OR ISOLATION?

106 N/A HAS AN HAZARDOUS ENERGY CONTROL PROGRAM BEEN SUBMITTED AND ACCEPTED BY GDA?

107 N/A FOR TEMPORARY WIRING, IS THERE A VERTICAL CLEARANCE MAINTAINED OF OF AT LEAST 10' ?

108	N/A	ARE ALL FLEXIBLE POWER CORDS INSPECTED AND DOCUMENTED DAILY?
109	N/A	ARE FLEXIBLE POWER CORDS UNSPLICED, EXCEPT HARD SERVICE CORDS OF 14 AWG OR LARGER, WHERE SPLICES ARE IAW NEC AND MADE BY A QUALIFIED ELECTRICIAN?

N/A OTHER? EXTRA CREDIT?

	0	0	0
CRANES
110			N/A	BEFORE CRANE/HOISTING EQUIPMENT IS PLACED IN SERVICE, HAS IT BEEN INSPECTED, TESTED, AND CERTIFIED IN WRITING BY A COMPETENT PERSON TO BE IN ACCORDANCE WITH THE MANUFACTURER'S RECOMMENDATION AND THE REQUIREMENTS OF EM 385-1-1?

111 N/A ARE CRANE OPERATORS QUALIFIED AND CERTIFIED AS SUCH, IN WRITING, TO THE GDA?

112 N/A CAN THE PROJECT MONITOR LOCAL WEATHER CONDITIONS AND UTILIZE A WIND-INDICATING DEVICE?

113 N/A ARE START-UP INSPECTIONS PERFORMED BY OPERATORS AT THE BEGINNING OF EACH SHIFT AND SUBMITTED WITH DRI? EM385-1-1, SEC 16.D.08

114 N/A HAS THE PERIODIC INSPECTION BEEN PERFORMED PRIOR TO USE ON SITE IAW EM 385-1-1, TABLE 16-1 AND 16.D.10?

115 N/A IS THE CRANE EQUIPPED WITH AN ANTI TWO-BLOCK (A2B) DEVICE?

116 N/A IS THE CRANE LEVEL ON FIRM AND LEVEL GROUND, WITH OUTRIGGERS DEPLOYED ON APPROPRIATE CRIBBING?

117 N/A IF A CRANE'S OPERATING WORK ZONE (360 DEGREES AROUND CRANE) IS WITHIN 20' OF POWER LINES, HAVE THE POWER LINES BEEN DE-ENERGIZED AND GROUNDED? REF. EM385-1-1, SEC. 16.G.09

118 N/A CONCUR THAT CRANE NOT BE ALLOWED TO WORK CLOSER THAN 10' TO ENERGIZED POWER LINES (DEPENDING ON ACTUAL VOLTAGE OF LINES) IAW TABLE 16-3.

119 N/A IS CRANE SIDE LOADING PROHIBITED?

120 N/A ARE RIGGING CABLES AND SLINGS INSPECTED BY A COMPETENT PERSON BEFORE EACH SHIFT?

121 N/A ARE WORKERS PROTECTED FROM THE CRANE SWING RADIUS AND PREVENTED FROM PASSING UNDER THE LOAD?

N/A OTHER? EXTRA CREDIT?

	0	0	0
CONFINED SPACES
122			N/A	IS ALL CONFINED SPACES WORK IAW 29 CFR 1910.146 AND ANSI Z117.1?

123	N/A	HAS A CONFINED SPACE COMPETENT PERSON (CSCP) BEEN IDENTIFIED IN WRITING?
124	N/A	IS THE CONFINED SPACE ATMOSPHERE BEING MONITORED?

125 N/A IS THE CONFINED SPACE BEING VENTILATED?

126 N/A HAVE THE CONFINED SPACE ENTRANTS, ATTENDANTS AND ENTRY SUPERVISOR BEEN PROPERLY TRAINED?

127 N/A IS THERE A RESCUE/RETRIEVAL SYSTEM IN PLACE FOR PERMIT-REQUIRED CONFINED SPACES ON THIS PROJECT?

128 N/A ARE ENTRY PERMITS POSTED AT POINT OF ENTRY AND SIGNED BY ENTRY SUPERVISOR?

129 N/A IS THERE A POINT-OF-ENTRY SIGN POSTED STATING "DANGER - CONFINED SPACE"?

130 N/A HAVE ALL HAZARDOUS SYSTEMS WITHIN THE CONFINED SPACE BEEN SECURED OR LOCKED OUT?

131 N/A OTHER? EXTRA CREDIT?

	0	0	0
ROOFING
131			N/A	HAS A STRUCTURAL ANALYSIS OF THE ROOF BEEN CONDUCTED BY A QUALIFIED PERSON ?

132 N/A HAS A COMPETENT PERSON COMPLETED A DAILY INSPECTION?

133 N/A HAS A COMPETENT PERSON DEVELOPED AND SUBMITTED A FALL PROTECTION PLAN WHICH HAS BEEN ACCEPTED BY THE GDA?

134 N/A ARE KETTLES AT LEAST 25 FEET AWAY FROM BUILDINGS?

135 N/A IS THE KETTLE ATTENDANT WEARING PROPER PPE AT ALL TIMES?

136 N/A ARE THERE TWO FIRE EXTINGUISHERS AT THE KETTLE?

137 N/A ARE SKYLIGHTS AND ROOF PENETRATIONS COVERED OR BARRICADED APPROPRIATELY?

138 N/A HAS THE ROOF BEEN EVALUATED FOR ITS ABILITY TO SUPPORT THE INTENDED CONSTRUCTION LOAD?

139 N/A ARE WARNING LINES, ON LOW-SLOPED ROOFS, PROPERLY INSTALLED AND MAINTAINED?

140 N/A ARE FUEL CYLINDERS A MINIMUM OF 10' AWAY FROM AN OPEN FLAME?

N/A OTHER? EXTRA CREDIT?

	0	0	0
EQUIPMENT
141			N/A	BEFORE USE, IS ALL MACHINERY OR EQUIPMENT INSPECTED DAILY BY A COMPETENT PERSON?

142 N/A ARE OPERATORS TRAINED AND AUTHORIZED TO OPERATE POWERED INDUSTRIAL TRUCKS, LIFT TRUCKS, AND SIMILAR EQUIPMENT?

143 N/A IS MOBILE EQUIPMENT EQUIPPED WITH BACKUP ALARMS, ROLLOVER CAGES AND ARE MOVING PARTS ADEQUATELY GUARDED?

144 N/A ARE EQUIPMENT OPERATIONS MAINTAINING A SAFE CLEARANCE FROM ELECTRICAL POWER LINES?

145 N/A DO ANY MODIFICATIONS OF EQUIPMENT MEET THE MANUFACTURER'S INSTRUCTIONS? LIFTING PERSONNEL WITH A FORKLIFT IS NOT ALLOWED BY MANY MANUFACTURERS.

146 N/A ARE SAFETY LASHINGS PROVIDED FOR HIGH PRESSURE HOSE CONNECTIONS, e.g. AIR COMPRESSORS?

147 N/A ARE WORKERS CLEAR OF "BLIND SPOTS" ASSOCIATED WITH MOBILE CONSTRUCTION EQUIPMENT?

148 N/A ARE DAILY WALK-AROUND INSPECTIONS OF AERIAL LIFTS PERFORMED AND DOCUMENTED BY QUALIFIED OPERATORS?

149 N/A DO AERIAL LIFTS HAVE BASKET/PLATFORM GUARDRAILS?

150 N/A CONCUR THAT WORKERS ARE NOT EXTENDING OVER THE GUARDRAIL OF AERIAL LIFTS?

151 N/A ARE FULL-BODY HARNESSES SECURED TO PROPER ATTACHMENT POINTS ON THE BOOM OR BASKET OF ARTICULATING-BOOM PLATFORMS (JLG TYPE) ?

152 N/A ARE DUMP TRUCK CHECKLISTS BEING USED AND COPIES KEPT ON SITE?

153 N/A IS THE INSPECTION, MAINTENANCE, AND REPAIR OF CONVEYORS PERFORMED BY QUALIFIED PERSONNEL IAW MANUFACTURER'S RECOMMENDATIONS?

154 N/A ARE EXPOSED AND MOVING MACHINERY PARTS MECHANICALLY OR ELECTRICALLY GUARDED?

155 N/A WHEN TWO OR MORE CONVEYING SYSTEMS ARE INTERFACED ARE ADEQUATE GUARDING AND SAFETY DEVICES IN PLACE?

N/A OTHER? EXTRA CREDIT?

	0	0	0
TREE MAINTENANCE AND REMOVAL
156			N/A	IS TREE MAINTENANCE OR REMOVAL WORK PERFORMED UNDER THE DIRECTION OF A QUALIFIED TREE WORKER?

157 N/A ARE THERE ONLY QUALIFIED LINE-CLEARANCE TREE TRIMMER OR LINE-CLEARANCE TRAINEE ASSIGNED TO WORK IN CLOSE PROXIMITY TO ELECTRICAL HAZARDS?

158 N/A ARE TREE WORKERS IN A BUCKET OR WORK PLATFORM USING FALL PROTECTION?

159 N/A DOES ALL TREE WORK OPERATIONS ABOVE 12' HAVE A SECOND WORKER IN THE AREA?

160 N/A PRIOR TO FELLING OPERATIONS, HAS THE WORK AREA BEEN CLEARED AND AN ESCAPE ROUTE PLANNED?

161 N/A ARE EMPLOYEES WORKING FROM THE UPHILL SIDE WHENEVER POSSIBLE?

N/A OTHER? EXTRA CREDIT?

	0	0	0
DEMOLITION
162			N/A	HAS THE GDA ACCEPTED A DEMOLITION PLAN, BASED ON ENGINEERING, AND LEAD AND ASBESTOS SURVEYS BY A REGISTERED PROFESSIONAL ENGINEER (RPE)?

163 N/A CONCUR THAT DEMOLITION DEBRIS BEING DROPPED FROM HIGHER THAN 6' IS CONTAINED BY AN ENCLOSED CHUTE AND THAT THE DROP AREA IS SECURED FROM TRAFFIC?

164 N/A IN PROJECTS OF BUILDING DEMOLITION, HAS NOTIFICATION BEEN MADE TO STATE HAVING JURISDICTION?

165 N/A ARE NAILS REMOVED FROM SCRAP LUMBER/MATERIALS?

166 N/A IS THE FRAGMENTATION OF GLASS CONTROLLED?

167 N/A ARE MATERIAL CHUTES ENCLOSED WHICH HAVE AN ANGLE GREATER THAN 45° FROM THE HORIZONTAL?

N/A OTHER? EXTRA CREDIT?

	0	0	0
ABATEMENT
168			N/A	HAS AN ABATEMENT PLAN BEEN SUBMITTED TO, AND ACCEPTED BY, THE GDA?

169 N/A IS INDEPENDENT AIR-MONITORING BEING PERFORMED INSIDE AND OUTSIDE THE BARRIERS AS REQUIRED?

170 N/A IS A CONTAINMENT IN PLACE WITHOUT A COMPROMISE TO ITS INTEGRITY?

171 N/A ARE THE EMPLOYEES UTILIZING APPROPRIATE PPE?

172 N/A IF A NEGATIVE-AIR SYSTEM IS USED, ARE FANS USED CONTINUOUSLY AND MONITORED FOR PRESSURE DIFFERENTIAL?

173 N/A HAS A BASELINE SURVEY BEEN PERFORMED AND FINAL CLEARANCE READINGS TAKEN?

174 N/A ARE INSPECTIONS BY AN INDEPENDENT PQP PERFORMED BEFORE BARRIERS ARE REMOVED?

175 N/A IS WASTE MATERIAL PROPERLY CONTAINERIZED AND STORED?

176 N/A ARE THE AIR MONITORING RESULTS PROVIDED TO GDA?

177 N/A ARE THE WASTE SHIPMENT RECORDS PROVIDED TO GDA?

N/A OTHER? EXTRA CREDIT?

	0	0	0
WATERFRONT ACTIVITIES
178			N/A	WHERE THE WORK IS OVER OR NEAR WATER , WITH THE DISTANCE TO THE WATER SURFACE LESS THAN 25 FEET , AND THE WATER DEPTH LESS THAN 10 FEET, ARE FALL PROTECTION REQUIREMENTS IN PLACE? (PFDs NOT REQUIRED)

179 N/A WHERE THE WORK IS OVER OR NEAR WATER, WITH THE DISTANCE TO WATER SURFACE 25 FEET OR MORE, ARE FALL PROTECTION REQUIREMENTS IN PLACE?

180 N/A IS A MARINE FALL PROTECTION RAILING, TYPE A or TYPE B, IN PLACE FOR VESSEL DECKS 6 FT. OR MORE ABOVE ADJACENT DECKS, DOCKS, OR OTHER HARD SURFACES?

181 N/A ARE PFDs WORN BY PERSONNEL IN AREAS WHERE A DECK PERIMETER IS NOT PRESENT?

182 N/A IS A RESCUE SKIFF AVAILABLE?

183 N/A ARE EMERGENCY LIFE RINGS AVAILABLE?

184 N/A IF DIVING OPERATIONS ARE TO TAKE PLACE, HAS A DIVE PLAN BEEN SUBMITTED AND ACCEPTED BY THE DDC?

185 N/A IF DIVING, IS A FIRST-AID KIT, OXYGEN RESUSCITATION SYSTEM (30 MINUTE SUPPLY), AND A STOKES LITTER, OR BACKBOARD WITH FLOATATION CAPABILITY, ON SITE?

186 N/A DOES THE DIVE TEAM HAVE THE PROPER NUMBER OF QUALIFIED MEMBERS?

187 N/A ARE THERE HAND RAILS, FOR FALL PROTECTION, ON ALL MARINE VESSELS FOR CONTRACTS AWARDED SINCE MARCH 2007?

188 N/A FOR MARINE (VESSEL) DECKS, 6 FEET OR MORE ABOVE OTHER SURFACES, IS TYPE A OR B FALL PROTECTION PROVIDED?

N/A OTHER? EXTRA CREDIT?

0 0 0

1. PREPARATORY PHASE:	N/A	7. LADDER SAFETY:	N/A		13. EQUIPMENT:	N/A
2. OFFICE TRAILER GENERAL:	N/A	8. EXCAVATIONS:	N/A		14. TREE MAINTENANCE:	N/A
3. FIRE PREVENTION:	N/A	9. ELECTRICAL:	N/A		15. DEMOLITION:	N/A
4. PPE:	N/A	10. CRANES:	N/A		16. ABATEMENT:	N/A
5. SCAFFOLD SAFETY:	N/A	11. CONFINED SPACES:	N/A		17. WATERFRONT:	N/A
6. FALL PROTECTION:	N/A	12. ROOFING:	N/A
				OVERALL RATING = AVERAGE RATING FOR ALL CATEGORIES:	ERROR:#DIV/0!

QUESTIONS ANSWERED "NO" ARE BE ENTERED INTO THE SITE SAFETY & OCCUPATIONAL HEALTH DEFICIENCY TRACKING SYSTEM (REFER TO EM 385-1-1 01.A.13.d) jmh2016

COMMENTS:

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File details come from the government source that posted it. Updated Jul 31, 2023.