J-0200000-03_Forms.pdf

Attachment J-0200000-03

Forms

Department of Defense (DD Form) 254 Department of Defense Contract Security Classification Specification (Blank Document)

Contractor Significant Incident Report (CSIR) (Blank Document)

Customer Comment Record (Blank Document)

See the following pages

J-0200000-03

Initial Report Follow-up Report Final Report

Contractor Significant Incident Report (CSIR)

1. General Information Contracting Activity/ROICC Office:

Accident Classification:

Injury Fatality Environment Procedural Issues Lessons Learned Illness Property Damage

Other_______________________________

Involving:

Confined Space Equip/Mrt Ver/Mat Handling (Heavy Construction Equip.) Hazardous Material Crane and Rigging Equip/Mrt Ver/Mat Handling (Material Handling)

Trenching/Excavation Diving Equip/Mrt Ver/Mat Handling (Man-Lift/Elevated Platform)

Waterfront/Marine Operations

Demolition/Renovation Fall from Ladder Fall from Scaffold

Other___________________ Electrical Fall from Roof Fire

2. Personal Information Name (Last, First, MI):

Age: Sex:

Job Title/Description:

Employed By:

Supervisor Name (Last, First, MI) & Title:

Was the person trained to perform this activity/task?

Yes No

What type of training was received (OJT, classroom, etc)?

Date of the most recent formal training and topics discussed?

3. Witness Information Witness #1: Name (Last, First, MI):

Supervisor Name (Last, First, MI):

Witness #2: Name (Last, First, MI):

Supervisor Name (Last, First, MI):

Additional Witnesses:

4. Contract Information Type of Contract:

A/E BOS CLEAN Construction Design Build FSCC FSSC JOC RAC Service Other_______________________________

Contract Number & Title:

Industrial Group & Industrial Type:

Prime Contractor Name/Address/Phone & Fax No:

Safety Manager (Last, First, MI):

Insurance Carrier:

Sub Contractor Name/Address/Phone & FAX No:

Safety Manager (Last, First, MI):

Insurance Carrier:

5. Accident Description Date of Accident:

Time of Accident: Exact Location of Accident:

Describe the accident in detail in your words: (Use the back of page if you need additional space)

(List any additional witnesses on a separate sheet and

Direct Cause(s) of Accident:

Indirect Cause(s) of Accident:

Action(s) taken to prevent re-occurrence or provide on-going corrective actions:

Corrective Action Beginning Date:

Anticipated Completion Date:

Personal Protective Equipment:

Available and used Available and not used Not Required Not related to Mishap Wrong PPE for job

List PPE Used:

Type of Construction Equipment (Make, Model, Serial #, VIN#) Involved:

Was Hazardous Material Spilled/Released?

Please List Hazardous Material(s) Involved:

Who provided first aid or cleanup of mishap site?

Any blood-borne pathogen exposure, other than EMTs? Yes No

Who?

List OSHA and EM-385-1-1 standards that were violated:

Was site secured and witness statements taken immediately? Yes No

By Whom?

6. Injury Illness/Fatality Information Severity of Injury/Illness:

Fatality Lost Workday Case Involving Days Away From Work Temporary Disabillity Recordable Workday Case Involving Restricted Duty Permanent Total Disability Other Recordable Case Recordable First Aid Case Permanent Partial Disability Non-Recordable Case No Injury

Estimated Days Lost:

Estimated Days Hospitalized: Estimated Days Restricted Duty:

List Primary Body Part Affected:

List Other Body Part(s) Affected:

Nature of Injury/Illness for Primary Body Part (Examples: Amputation, Burn, Hernia):

Type of Accident (Examples: Fall same level, Lifting, Bitten, Exerted):

Source of Accident (Examples: Crane, Carbon Monoxide, Ladder, Welding Equipment):

7. Causal Factors (Explain answers on supplementary sheet)

• Design – Design of facility, workplace, or equipment was a factor? Yes No

• Inspection/Maintenance – Inspection & Maintenance procedures were a factor? Yes No

• Persons Physical Condition – In your opinion, the physical condition of the person was a factor?

Yes No

• Operation Procedures – Operating procedures were a factor? Yes No

• Job Practices – One or more job safety/health practices not being followed when the accident occurred contributed to the accident?

Yes No

• Human Factors – One or more human factors, such as a person’s size or strength contributed to the accident?

Yes No

• Environmental Factors – Heat, cold, dust, sun, glare, etc., contributed to the accident?

Yes No

• Chemical and Physical Agent Factors – Exposure to chemical agents, such as dust, fumes, mist, vapors, or physical agents such as noise, radiation, etc., contributed to the accident?

Yes No

• Office Factors – Office setting such as lifting office furniture, carrying, stooping, contributed to the accident?

Yes No

• Support Factors – Inappropriate tools/resources were provided to perform the task?

Yes No

• PPE – Improper selection, use or maintenance of PPE contributed to the accident?

• Drugs/Alcohol – In your opinion, were drugs or alcohol a factor? Yes No

• Job Hazard Analysis – The lack of an adequate (IAW-EM-385-1-1 Sec 01.A) activity hazard analysis was a contributing factor.

Yes No

• Job Hazard Analysis – JHA was not site specific and/or did not address the type of work/operations performed when the mishap occurred.

Yes No

• Management – A lack of adequate supervision contributed to the accident. Yes No

• Management – Inadequate information was provided at pre con meeting. Yes No

8. OSHA Information Date OSHA was Notified:

Date(s) of Investigation: Date of citation:

(Attach Copy)

Dollar amount of Penalties:

9. Report Preparer Name (Last, First, MI):

Date of Report:

Title:

Employer:

Phone #:

Signature: