N4008522R2681 J-0200000 Combined Attachments.pdf

Department of Defense Electronic Invoicing

Wide Area Workflow – Vendor Getting Started Guide

Prepared by: The Defense Finance and Accounting Service, eSolutions Office Document Version Date: 17 January 2011

Document Version: 5.0

Table of Contents

WAWF Getting Started for Vendors Verifying the EB POC in CCR Registering in WAWF User ID & Password - Vendor

WAWF Getting Started for Vendors

Introduction

Thank you for your interest in Wide Area Workflow. This guide will help you get started using WAWF. In addition to this guide feel free to access the following web links for additional information and training on WAWF:

WAWF General Information and Registration https://wawf.eb.mil

WAWF Training Database (great place to practice using WAWF) https://wawftraining.eb.mil

WAWF On-line Training Course (great place to begin learning WAWF) www.wawftraining.com

DFAS Electronic Commerce End Users Tool Box (register for classroom training and obtain user guides) http://www.dfas.mil/contractorpay/electroniccommerce/wawftrain.html

Overview

General Steps for a Vendor to follow to use WAWF:

Steps Description

1 Register with the Central Contractor Registry (CCR) 2 Establish and Electronic Business (EB) Point of Contact (POC) in

CCR

3 Register of Electronic Document Access (EDA) (Optional) 4 Ensure CAGE Code is added to WAWF Group Structure 5 Establish an Organizational Email Address 6 Designate a Group Administrator Manager (GAM) 7 Determine if batch feeds for data input is necessary 8 Set up PCs to Access WAWF 9 Self Register GAM

10 Have all users for the CAGE Code(s) self-register on the WAWF web site for one of the available Vendor Roles.

11 Practice Using WAWF

Continued on next page

WAWF Getting Started for Vendors, Continued

1st Step

Register with Central Contractor Registry (CCR)

All vendors must be registered in the CCR in order to sell goods and services to the Department of Defense (DoD).

Register at URL http://www.ccr.gov/ (External Link).

For help with registration in CCR, contact Federal Service Desk at 866- 606-8220 or 334-206-7828. If you do not know your CCR POC, you can contact the Federal Service Desk.

2nd Step Establish or verify the Electronic Business (EB) Point of Contact (POC) in

CCR

To facilitate electronic commerce between vendors and DOD, vendors must establish an EB POC for their company in CCR.

The EB POC will be responsible for authorizing vendor employee(s) access to submit, modify and/or view data on behalf of the vendor. In WAWF terminology, the EB POC also functions as the Group Administrator (GAM). The GAM is your company's "Gate Keeper" and will be responsible for authorizing access to WAWF for all your company's employee(s).

The CCR POC is responsible for entering EB POC data in CCR.

To see if an EB POC is listed for a specific company, go to http://www.ccr.gov/ (External Link) and click on "CCR Search". Where prompted, enter the DUNS Number or CAGE Code or Company Name and click the "Search" button. If you are presented with a list of DUNS numbers, you will need to pick the specific location and click on the Detail link. Scroll to the bottom of the Inquiry Results page. There you can see if anyone is listed as the EB POC. If no one is listed, the company has not identified an EB POC yet.

If a vendor sees that there is no one listed as their EB POC, they need to contact the CCR POC and ask the CCR to update the company's registration to include the EB POC.

Each vendor can establish up to two EB POCs one primary and one alternate EB POC for each Cage/DUNS code.

3rd Step

Register for Electronic Document Access (EDA). (Optional Step, but recommended.)

Electronic Document Access (EDA) acts as a virtual file cabinet for the storage and retrieval of multiple types of acquisition documents to include Purchase Orders and post-award contracts. Vendors may be authorized to view contract documents that match their validated DUNS or CAGE codes.

Go to the following URL http://eda.ogden.disa.mil/users_guide/access/Registration/reg002_Ven dorSteps.html for instructions. (External Link).

4th Step Have your CAGE Code added to the WAWF Group Structure

Your CAGE Code/s must be added to WAWF Group Structure before any personnel can self-register in WAWF. If you have multiple CAGE Codes they can all be added to your group at the same time.

Optional CAGE Code extensions can be created to subdivide your CAGE Code into smaller units. Each CAGE Code and extension will have its own organizational e-mail address. The email addresses will be used to notify your sub-groups that a document status has changed.

To establish a vendor group for a CAGE Code, someone in your company needs to either call the Customer Support Center phone number or send an email to DISA Ogden. If your organization has multiple CAGE Codes, the WAWF Customer Support Center will assist in adding all your CAGE Codes to your CAGE Group Structure in WAWF. (see Customer Support link)

Phoned in requests will be activated online. Emailed requests will be processed within 48 hours after receipt.

Group Activation Email: Please use the following template to email requests to WAWF Customer Support: Customer Please fill in missing information with your company information. (External Link).

Important - PLEASE NOTIFY YOUR EB POC! We will need their authorization to activate individual accounts after the CAGE Code(s) are added to WAWF.

5th Step

Establish an Organizational email Address.

WAWF routes information according to CAGE Codes. WAWF documents themselves do not get routed, but status information about the documents is sent in emails. For example, email confirmations are sent when a vendor SUBMITS a document. Email notices are sent when the government ACCEPTS or REJECTS the document.

In order to receive status information about the WAWF documents, vendors need to establish organizational email accounts and determine who will have access to this organizational email account.

Ensure that the organizational email address is operational and can receive email prior to registering it with the WAWF Customer Support Center.

The GAM or EB POC shall provide the organizational email to the WAWF Customer Support Center. (See GAM Appointment Letter in Step 6 below).

Note: If you do not set up an organizational email address, the personal email address of the first person who self-registers from your CAGE/DUNS Code will be used as the organizational email address.

6th Step

Designate a Group Administrator (GAM) for your company.

A GAM determines who has access to their data submitted in WAWF and provides the authorization to activate.

In medium to large sized companies, there may be a need to establish more than one GAM.

Vendors must appoint a GAM to manage their WAWF account. It is recommended that the EB POC be the GAM. As mentioned earlier, the GAM is your companies "Gate Keeper" and as such this person authorizes the activations and deactivations for the company's CAGE Code(s). When the EB POC registers as the GAM no additional paperwork is required to establish your WAWF GAM account.

The EB POC will also be contacted when there is a question about invoices submitted through WAWF. Please ensure your EB POC is familiar with the WAWF process and they can contact company personnel to answer invoicing questions from government officials.

If you appoint a GAM that is not your EB POC, they are required to submit their GAM appointment letter, signed by their EBPOC, via email to the Ogden Customer Support Center Customer Support email or they may fax it to the customer Service Center. The fax number is 1-801-605-7453. GAM appointment letter

7th Step

Determine if batch feeds for data input is necessary.

Most Vendors use the manual, web entry method to input their documents directly into WAWF. Web entry is a good method if you have a small volume of payment documents to create or if you have a small amount of lines on your contract(s). But for vendors that have a large number of transactions and/or many line items per payment document, you may want to consider submitting documents into WAWF via the File Transfer Protocol (FTP) or Electronic Data Interchange (EDI) method.

WAWF FTP and EDI Guides are available after your account has been activated. If further assistance is needed, please contact the WAWF Customer Service Center and ask for help with EDI. A trouble ticket will be created and you will be forwarded to the Joint Interoperability Test Center (JITC) and a technician will be assigned to assist you in testing your file layout(s). (See Customer Support Link).

8th Step

Set up PCs to access WAWF.

Your current computer configuration is usually sufficient to use WAWF. On rare occasions your computer's browser setting may need to be changed.

Please try using WAWF first and then if you experience problems check your set-up by selecting the "Machine Setup" link on the WAWF home page or call the Ogden Help desk for assistance - for Ogden Help desk information select the "Customer Support" link on the WAWF home page.

9th Step

GAM needs to Self Register in WAWF.

Refer to the "Registration" Link on the WAWF Home Page and the Help button for details on registering in the WAWF application as a

GAM.

If the GAM's account has not been activated within 2 business days of self-registering, notify the WAWF Customer Service. (See Customer Service Link).

10th Step

Have all users for the CAGE Code(s) self-register on the WAWF web site for one of the available Vendor Roles.

Once the EB POC (GAM) has been activated, all company users will need to self-register. Now the EB POC (GAM) can activate or deactivate their company personnel within WAWF.

Every user of WAWF must self-register on the WAWF web site by completing the online registration form.

Refer to the "Registration" Link on the WAWF Home Page and the Help button for details on registering in the WAWF application in a Vendor Role.

Note: User accounts will not be activated until the GAM activates the accounts. The GAM will receive an email for all registrations.

If a user's account has not been activated within 2 business days of self-registering, notify the EB POC or WAWF Customer Support Center.

11th Step

Practice Using WAWF.

Online Training Site - Once you have completed steps 1-10, you may want to practice using WAWF in the online training site. This site is for practice only. You can practice submitting documents for payment, and viewing and working on documents in the online training site. After getting to the WAWF practice site, you should click the "Training Instructions" hyperlink in the left column to get your training User IDs and passwords and important sample data.

To practice in the online training site go to the following URL https://wawftraining.eb.mil/ (External Link).

Continued on Next Page

Verifying the EB POC in CCR

Introduction In order to register in WAWF you must have an Electronic Business (EB)

Point of Contact (POC).

Procedure Follow the steps below to verify who is listed as your EB POC in CCR.

Step Action

1 Go to the CCR web site http://www.ccr.gov

Result: Home page screen opens.

2 Click CCR Search.

Result: CCR Search screen is displayed.

3 Enter Cage Code in the Cage Code Field or enter your Company Name in the Company Name field. Click Search.

Result: The CCR Search Results screen displays.

Verifying the EB POC in CCR, Continued

4 Scroll to the bottom of the page and review the inquiry results.

Electronic Business Primary POC Electronic Business Alternate POC

Name: Jane Doe Name: Joe Smith

Addrress Line 1: 123 Main Street Addrress Line 1: 123 Main Street

Address Line 2: Suite 100 Address Line 2: Suite 100

City: Anytow n City: Anytow n

State: CA State: CA

Zip/Postal Code: 55555 Zip/Postal Code: 55555

Country: USA Country: USA

U.S. Phone: 555 123-9876 U.S. Phone: 555 123-9876

Non-U.S. Phone: Non-U.S. Phone:

Fax: 555 123-6543 Fax: 555 123-6543

IF someone is listed as the EB POC THEN your EB POC is established.

Procedure is complete.

IF there is no EB POC listed at the bottom of your profile THEN refer to the “Establish or verify the Electronic Business Point of Contact (EB POC) in CCR” section for a detailed procedure.

Registering in WAWF User ID & Password - Vendor

Introduction

In order to use the WAWF application you will need to self-register. There are several roles for which you may register, e.g., GAM, Vendor and Vendor View Only.

User ID Rules

Minimum 8 characters

May contain ONLY the following special characters ~ ! # $ ^ _ { }

Must not already be registered in WAWF.

Password Rules Password formatting guidelines require that every password must contain:

Minimum 8 characters

Must contain at least 1 capital letter

Must contain at least 1 lower case letter

Must contain at least 1 number

Must contain at least 1 special character

Cannot contain consecutive characters (abc or cba)

Cannot contain repeating characters (aa, bb, etc)

Cannot contain the same character more than twice

Entered passwords must be different from last 10 passwords used

Cannot be changed within 24 hours

Registering in WAWF User ID & Password – Vendor, Continued

Procedure Follow the steps below to self-register in WAWF.

1 Go to https://wawf.eb.mil

Result: U.S. Government Computer System Notice and Warning screen is displayed

2 Click Accept.

Result: Home screen displays.

3 Click Registration.

Result: Registration screen displays.

Registering in WAWF User ID & Password - Vendor, Continued

4 Select the radio button labeled User ID \ Password and Vendor.

Click Next.

Result: Data Capture screen displays.

5 Click the Edit link next to User Profile.

Result: The Registration – Edit User Profile screen displays.

Registering in WAWF User ID & Password - Vendor, Continued

6 Enter required data and click Save.

Result: User is returned to the Data Capture screen.

7 Repeat steps 5-6 for User Authentication, User Security Questions, Vendor User Roles and Administrative User Roles.

Click Submit.

Note: Comments and attachments are optional on the Vendor/Administrator User Roles sections.

Result: The Registration - View & Accept Information System User Agreement screen displays.

8 Click Accept.

Result: Confirmation of registration screen displays. You will receive an e-mail containing your User ID. Once you have been activated by an administrator, you will receive another email notifying you of the role(s) for which you have been activated.

If you have any questions, please contact the Customer Support.

FINAL OVERALL

SCORE:

DATE:

CHECKLIST

INSPECTOR:

TOT MONTHLY MAN-

HOURS:

QC MANAGER:

TOT CUMULATIVE

MAN-HOURS:

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 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?

N/A

N/A

N/A

N/A

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?

OFFICE TRAILER / SIGNAGE / GENERAL

16 N/A ARE OFFICE AND STORAGE TRAILERS ANCHORED?

17 N/A ARE EMERGENCY PHONE NUMBERS POSTED?

N/A

IS TEMPORARY PROJECT FENCING IN PLACE WHICH EXTENDS FROM GRADE

LEVEL TO AT LEAST 48 INCHES IN HEIGHT ABOVE GRADE? (UNLESS GDA

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 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?

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?

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?

N/A

IS HIGH-VISIBILITY APPAREL BEING WORN WHERE WORKERS ARE EXPOSED

TO VEHICULAR OR EQUIPMENT TRAFFIC OF UP TO 45 MPH, WHERE VISIBILITY

N/A OTHER? EXTRA CREDIT?

SCAFFOLD SAFETY

46 N/A 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?

FALL PROTECTION

N/A

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?

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?

ARE SAFETY INSPECTIONS/AUDITS, OF THE WORK SITE, MATERIAL, AND EQUIPMENT, CONDUCTED BY A COMPETENT PERSON, DOCUMENTED IN WRITING AND

ARE ALL FLOORS, WORKING SPACES AND PASSAGEWAYS FREE OF PROTRUDING NAILS, SPLINTERS, LOOSE BOARDS, DEBRIS AND UNNECESSARY HOLES OR

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

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?

WORK HAS NOT STARTED UNTIL THE AHA IS REVIEWED BY CONTRACTOR, SUBCONTRACTOR(S) AND GOVERNMENT ON-SITE REPRESENTATIVES DURING

PREPARATION AND INITIAL PHASE MEETING.

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 ?

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?

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?

CONTRACTOR SAFETY SELF-EVALUATION CHECKLIST (MIDLANT)

PWD / ROICC / FSC OFFICE:

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.

SUPERINTENDENT:

SSHO:

CONTRACTOR:

CONTR. NO.

CONTR. TITLE:

N/A OTHER? EXTRA CREDIT?

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)

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

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?

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

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?

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?

CRANES

N/A

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

WATERFRONT ACTIVITIES

N/A

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?

N/A 7. LADDER SAFETY: N/A 13. EQUIPMENT: N/A

N/A 8. EXCAVATIONS: N/A

14. TREE

MAINTENANCE: N/A

N/A 9. ELECTRICAL: N/A 15. DEMOLITION: N/A

N/A 10. CRANES: N/A 16. ABATEMENT: N/A

N/A 11. CONFINED SPACES: N/A 17. WATERFRONT: N/A

N/A 12. ROOFING: N/A

OVERALL RATING = AVERAGE RATING FOR ALL CATEGORIES: #DIV/0!

COMMENTS:

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)

6. FALL PROTECTION:

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

1. PREPARATORY PHASE:

2. OFFICE TRAILER

GENERAL:

3. FIRE PREVENTION:

4. PPE:

5. SCAFFOLD SAFETY:

OMB 0703-0061 05/31/2024 CUI (when filled in)

SECNAV 5512/1 (MAY 2021) Controlled by: DoN CUI Category: PRVCY

LDC: FEDCON

Page 1 of 3 CUI (when filled in) POC: Rodney Ramseur, rodney.ramseur@navy.mil, 202-433-4281

DEPARTMENT OF THE NAVY LOCAL POPULATION ID CARD/BASE ACCESS PASS REGISTRATION

PRIVACY ACT STATEMENT:

AUTHORITY: 10 U.S.C. 113, Secretary of Defense; DoD Directive 1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 5200.08, Security of DoD Installations and Resources and the DoD Physical Security Review Board (PSRB); DoD 5200.08-R, Physical Security Program; DoD Directive 5200.27, Acquisition of Information Concerning Persons and Organizations not Affiliated with the Department of Defense (Exception to policy memos); Directive-Type Memorandum (DTM) 09-012, Interim Policy Guidance for DoD Physical Access Control; DTM 14-005, DoD Identity Management Capability Enterprise Services Application (IMESA) Access to FBI National Crime Information Center (NCIC) Files; and E.O. 9397 (SSN), as amended; OPNAVINST 5530.14E, Navy Physical Security and Law Enforcement Program; Marine Corps Order P5530.14, Marine Corps Physical Security Program Manual;

SORNNM05512-2 Badge and Access Control System Records and DMDC 16, Identity Management Engine for Security and Analysis (IMESA): http://dpcld.defense.gov/Privacy/ SORNsIndex

PURPOSE(S): To control physical access to Department of Defense (DoD), Department of the Navy (DON) or U.S. Marine Corps Installations/Units controlled information, installations, facilities, or areas over which DoD, DON, or U.S. Marine Corps has security responsibilities by identifying or verifying an individual through the use of biometric databases and associated data processing/information services for designated populations for purposes of protecting U.S./Coalition/allied government/national security areas of responsibility and information; to issue badges, replace lost badges, and retrieve passes upon separation; to maintain visitor statistics; collect information to adjudicate access to facility; and track the entry/exit times of personnel.

ROUTINE USE(S): To designated contractors, Federal agencies, and foreign governments for the purpose of granting Navy officials access to their facility.

DISCLOSURE: Providing registration information is voluntary. Failure to provide requested information may result in denial of access to benefits, privileges, and DoD installations, facilities and buildings.

IDENTITY PROOFING AND APPLICANT INFORMATION

1. LAST NAME: 2. FIRST NAME: 3. MIDDLE NAME: 4. NAME SUFFIX:

Jr. Sr. I II III IV

5. RACE AMERICAN INDIAN or ALASKA

(Check one or more): NATIVE ASIAN BLACK or AFRICAN AMERICAN

NATIVE HAWAIIAN

HISPANIC OR LATINO OR OTHER PACIFIC

ISLANDER

WHITE

6. GENDER

(Check MALE FEMALE one):

7. DATE OF BIRTH: 8. CITY OF BIRTH: 9. STATE OF BIRTH: 10. BIRTH COUNTRY:

11. US CITIZEN (Check): YES NO 12. DUAL CITIZENSHIP: YES NO CITIZENSHIP IF OTHER THAN US (Country) :

U.S. Citizen Minimum Documentation Required:

By Birth - Social Security No and State ID/Drivers License.

Naturalized - Certification Number, Petition Number, Date, Place and Court, United States passport number, Social Security No and/or State ID/Drivers License.

Derived - Parent's certification number, Social Security No and/or State ID/Drivers License.

Alien Minimum Documentation Required:

Registration Number, Expiration date, Date of entry, Port of entry.

13. IDENTITY SOURCE

DOCUMENTS PRESENTED:

14. DOCUMENT

NUMBER:

15. ISSUED BY

STATE/COURT:

16. ISSUED BY

COUNTRY:

17. ISSUED: 18. EXPIRES:

Social Security No. United States

State ID/Drivers License United States

Passport No.

Certification Number and Petition Number

Derived - Parent's Certification Number: United States

Alien Registration No. United States

Date of Entry: Port of Entry:

OTHER APPROVED IDENTITY SOURCE DOCUMENTS:

19. WEIGHT

(Pounds):

20. HEIGHT

(Inches):

21. HAIR COLOR (Check one):

Blond Brown Black Gray Red

White Silver Auburn Bald

22. EYE COLOR (Check one):

Brown Green Blue Hazel

Black Gray Violet Unknown

23. HOME ADDRESS (Include city, state, zip code): HOME PHONE (Include Area Code):

SPONSOR PHONE (Include Area Code): 24. BASE SPONSOR'S NAME:

NWS/Earle 732-866-2135Darren Marcinkiewicz mailto:rodney.ramseur@navy.mil http://dpcld.defense.gov/Privacy/ michael.baldasari Highlight

OMB 0703-0061 05/31/2024 CUI (when filled in)

SECNAV 5512/1 (MAY 2021) Controlled by: DoN CUI Category: PRVCY

LDC: FEDCON

Page 2 of 3 CUI (when filled in) POC: Rodney Ramseur, rodney.ramseur@navy.mil, 202-433-4281

EMPLOYMENT ACTIVITY INFORMATON

25. EMPLOYER NAME AND ADDRESS (Include city/state/zip code): EMPLOYER PHONE (Include Area Code):

26. SUPERVISOR NAME AND ADDRESS (Include city/state/zip code): SUPERVISOR PHONE(Include Area Code):

27. Check the applicable box for WORK HOURS box or check the OTHER box and enter the work hours, then check the applicable box for WORK DAYS:

WORK HOURS: 0600-1800 0800-1700 OTHER WORK DAYS: SN M T W TH F ST

PRIOR FELONY CONVICTIONS

28. Have you ever been convicted of a Felony? YES NO Initial

REQUIREMENT TO RETURN LOCAL POPULATION ID CARD

29. I understand that I am required to return my Local Population Identification Card to the Base Pass Office when it expires or if my employment is terminated for any reason. (initial)

AUTHORIZATION AND RELEASE AND CERTIFICATION

30. I hereby authorize the DOD/DON and other authorized Federal agencies to obtain any information required from the Federal government and/or state agencies, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), the U.S. Department of Homeland Security (DHS).

I have been notified of DON right to perform minimal vetting and fitness determination as a condition of access to DON installation/facilities. I understand that I may request a record identifier; the source of the record and that I may obtain records from the State Law Enforcement Office as may be available to me under the law. I also understand that this information will be treated as privileged and confidential information.

I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD RESULT IN FINES AND/OR IMPRISONMENT UP TO FIVE YEARS.

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE YOU HAVE ANSWERED ALL QUESTIONS FULLY AND CORRECTLY.

I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE BY ME ON THIS FORM ARE TRUE, COMPLETE AND CORRECT.

DATE SIGNATURE

FINAL DETERMINATION ON YOUR ACCESS: The Base Commanding Officer has final authority for determination on granting physical access to DON controlled installations/facilities under his/her jurisdiction.

BELOW COMPLETED BY BASE REGISTRAR PERSON CONDUCTING IDENTY PROOFING and NCIC CHECK

31. INFORMATION VERIFIED BY: 32. ENTERED IN C/S SYSTEM BY: 33. PASS ISSUE DATE: 34. PASS EXPIRATION DATE:

35. NCIC CHECK PERFORMED BY: 36. RESULTS OF NCIC CHECK:

NO RECORDS RECORD IDENTIFIER

RECORD NUMBER:

37. RESULTS OF LOCAL RECORDS CHECK:

NO RECORDS RECORD IDENTIFIER

RECORD NUMBER:

Office of Under Secretary of Defense Directive-Type Memorandum (DTM) 09-012, "Interim Policy Guidance for DoD Physical Access Control," December 8, 2009. DTM 09-012 requires that DoD installation government representatives query the National Crime Information Center (NCIC) and Terrorist Screening Database to vet the claimed identity and to determine the fitness of non-federal government and non-DoD-issued card holders (i.e.

visitors) who are requesting unescorted access to a DoD installation. The minimum criteria to determine the fitness of a visitor is: 1) not on a terrorist watch list; 2) not on an DoD installation debarment list; and 3) not on a FBI National Criminal Information Center (NCIC) felony wants and warrants list.

Additionally, SECNAV Memo, Policy for Sex Offender Tracking and Assignment and Access Restrictions within the Department of the Navy, of 7 Oct 08 and OPNAVINST 1752.3 established the Navy's policy on sex offenders, requiring Region Commanders (REGCOMs) and Installation Commanding Officers (COs) to prohibit sex offender access to DoN facilities and Navy owned, leased or PPV housing. This form describes the authority and purpose to collect and share the required information; and identifies the applicant/visitor and sponsor; and authorizes the DoD to perform the minimum vetting and fitness determination criteria. A favorable response on the vetting and fitness determination is required to receive access to DOD-controlled installation/facilities.

mailto:rodney.ramseur@navy.mil

RESTRICTED AREA ACCESS REQUEST FORM REVISION 2-2022

PLEASE ALLOW 5 BUSINESS DAYS FOR PROCESSING

APPLICANT INFORMATION

Name:

(Last) (First) (Middle)

Address:

City: State: Zip:

Phone Number: Date of Birth:

CAC Expiration: Last 4 of Social Security number:

*** PRIVACY ACT OF 1974 APPLIES

*** (SEE BELOW)

Prime Contractor Company Phone Number Sub Contractor Name Phone Number

Contract Expiration Date:

CAMERA

RESTRICTED AREA ACCESS APPROVAL SECO Signature and Date

ORDNANCE PIER C-33 C-34

1. It is requested that a badge/pass be issued to the person listed above. It is understood that this command/ company will be responsible for said pass and it will be returned as the termination of assignment/employment or completion of present contract.

2. It is further represented that this command/company assumes responsibility for the person listed above while they are on the property of Naval Weapons Station (NWS) Earle during the period for which the badge/pass will be issued.

Government Representative (Print) Phone Number Signature/Date

VCC Results:

CLEARED NOT CLEARED

Signature/Date

Security Representative (Print) Phone Number Signature/Date

Pass/Badge Number Issued By (Print) Signature/Date

PRIVACY ACT STATEMENT - BADGE AND ACCESS CONTROL SYSTEM

Authority: 5 U.S.C 301, Departmental Regulations, OPNAVINST 5530.14E, and I.O. 9397 (SSN).

Principal Purpose: Top maintain all aspects of proper access control; to issue badges; to maintain visitor statistics; and collect information to adjudicate access.

Routine Use: The "Blanket Routine Uses" that apply to Department of the Navy system of records, see SECNAVINST 5211.5D, enclosure (9) Disclosure: Voluntary, however, failure to provide the requested information may result in denial of access into the installation.

MARKINGS/DECAL NO.

ADDRESS OF OWNER

NAME AND ADDRESS OF INSURANCE COMPANY OR AGENT

DEPARTMENT OF THE NAVY TRAFFIC ACCIDENT REPORT

(SUPPLEMENT TO INCIDENT/COMPLAINT REPORT)

CASE CONTROL NUMBER

DATE OF ACCIDENT

YR MO DAY

TIME (USE 2400 HOURS) DAY OF COLLISION

SUNDAY MONDAY TUESDAY

SATURDAYFRIDAYTHURSDAYWEDNESDAY

NAVY BASE

ON OFF

ROAD OR STREET ON WHICH ACCIDENT OCCURRED NAME AND LOCATION OF NAVY BASE, CITY, STATE, ETC.

LO

C

A

TI

O N

AT

INTER-

SECTION

NAME OF INTERSECTING STREET NOT AT

INTER-

SECTION

NAME OF NEAREST INTERSECTING ST., HIGHWAY, OR

OTHER PERMANENT IDENTIFYING LANDMARK.

NO. OF

FEET

DIRECTION

IF ACCIDENT OCCURRED OFF NAVY BASE AND OUTSIDE CITY LIMITS

INDICATE MILES N S E W FROM CITY LIMITS CENTER

OF CITY OR TOWN

KIND OF LOCALITY BARRACKS RESIDENTIAL MFG. OR INDUST

OPEN COUNTRY SCHOOL OR PLAYGROUND BUSINESS

OTHER

TYPE ACCIDENT VEHICLE-VEHICLE VEHICLE-PEDICYCLE STOLEN VEHICLE OTHER

VEHICLE-OBJECT

VEHICLE-PEDESTRIAN

VEHICLE-RR TRAIN SINGLE VEHICLE (NON COLLISION)

HIT & RUN

TOTAL NO. OF

VEHICLES

INVOLVED

SEVERITY

NO. KILLED NO. INJURED

PROPERTY DAMAGE ONLY

TY

P

E A

C C

I- D

E N

T

W E

A

TH

E R

, L

IG

H T

A N

D R

O A

D C

O N

D

IT

IO

N

S

VEHICLE

1 2

DRIVING LANES VEHICLE

1 2

VEHICLE

1 2

VEHICLE

1 2

VEHICLE

1 2

CHARACTER SURFACE CONDI-

TIONS

DEFECTS WEATHER LIGHT

ONE

TWO

THREE OR MORE

DIVIDED HIGHWAY

OTHER OTHER

GRADE

LEVEL

CURVE

STRAIGHT

OTHER

GRAVEL

BRICK

BLACKTOP

CONCRETE

DARK NO

STREET LIGHTS

DARK

STREET LIGHTS

DUSK

DAWN

DAYLIGHT

OTHER

SNOW

MUD

WET

DRY

OTHER

NO DEFECTS

DEFECTIVE

LOOSE MATERIAL OR

HOLES, RUTS, BUMPS

OTHER

SNOWING

FOG

RAIN

CLEAR

VEHICLE

1 2

VEHICLE

1 2

VEHICLE

1 2

VEHICLE

1 2

STOP & GO SIGNAL

NO TRAFFIC SIGNAL MANNED

FLASHING LIGHT

SOLID CENTER LINE

WARNING SIGN

STOP SIGN

ONE WAY STREET

OTHER (EXPLAIN)

TR

A

FF

IC

C O

N

TR

O L

USN REGISTRATION OR LICENSE NO. MAKE YEAR BODY TYPE

PRIVATELY OWNED

GOVERNMENT

REGISTERED OWNER (IF NOT DRIVER) (LAST, FIRST, M.I.)

V E

H

IC

LE

N

O . 1

V E

H

IC

LE

N

O . 2

NAME AND ADDRESS OF INSURANCE COMPANY OR AGENT

ADDRESS OF OWNER

REGISTERED OWNER (IF NOT DRIVER) (LAST, FIRST, M.I.)

GOVERNMENT

PRIVATELY OWNEDMARKINGS/DECAL NO.

BODY TYPEYEARMAKEUSN REGISTRATION OR LICENSE NO.

NAME (LAST, FIRST, M.I.) AND ADDRESS

DRIVER'S LICENSE/PERMIT NUMBER

LIMITATIONS ON LICENSE/PERMIT

SSN

AGE SEX

FEMALE

MALE

STATE

DRIVING EXPERIENCE

(YEARS)

CODES

NO

YES (SPECIFY)

(1) CAT INJ(2) SEAT

BELT

(3) SEAT

POS

(4)

V E

H

IC

LE

N

O . 1

V E

H

IC

LE

N

O . 2

SEAT

POS

(4)SEAT

BELT

(3)INJ(2)CAT(1)CODES

YES (SPECIFY)

DRIVING EXPERIENCE

(YEARS)

NOLIMITATIONS ON LICENSE/PERMIT

STATEDRIVER'S LICENSE/PERMIT NUMBER

FEMALE

MALE

SEXAGE

SSNNAME (LAST, FIRST, M.I.) AND ADDRESS

O C

C U

P A

N

TS

P E

D E

S

TR

IA

N

C O

D E

S

NAME AND ADDRESS VEH.

NO.

CODES

AGE SEX

CATE-

GORY

(1)

IN-

JURY

(2)

SEAT

BELT

(3)

SEAT

POSI-

TION

(4)

NAME AND ADDRESS

PEDESTRIAN WAS GOING: WESN

FROM (NW TO SW CORNER, OR EAST TO WEST SIDE, ETC.):

ALONG/ACROSS/INTO (STREET, ROAD OR HIGHWAY):

TO:

CROSSING WITH SIGNAL

CROSSING AGAINST SIGNAL

CROSSING NOT AT INTERSECTION PLAYING ON ROADWAY

HITCHING ON VEHICLE

CROSSING NO SIGNAL

PUSHING OR WORKING ON VEHICLE

COMING FROM BEHIND PARKED

STANDING ON ROADWAY

OTHER

WALKING IN ROAD WITH TRAFFIC

WALKING IN ROAD AGAINST TRAFFIC

(1) CATEGORY (2) INJURY CLASS (3) SHOULDER/LAP BELTS (4) SEAT POSITION

A. NAVY OFFICER

B. NAVY ENLISTED

C. OTHER SERVICE OFFICER

D. OTHER SERVICE ENLISTED

E. CIVILIAN

F. DEPENDENT

G. OTHER

A. NO INJURY

B. DEAD AT SCENE

C. DEAD ON ARRIVAL

D. DIED IN HOSPITAL

E. INCAPACITATING INJURY

F. NON-INCAP (EVIDENT) INJURY

G. POSSIBLE INJURY

H. INJURY UNKNOWN

A. LAP BELT USED

B. SHOULDER HARNESS USED

C. BOTH USED

D. NOT USED

E. NOT INSTALLED

F. LAP BELT FAILED

G SHOULDER HARNESS FAILED

H. BOTH FAILED

U. UNKNOWN

7. OTHER POSITION (BUS-MOTORCYCLE)

8. POSITION UNKNOWN

OPNAV 5580/1A (Rev 11/2006) Page 1 of 2 Pages

OPNAVINST 5530.14

DEPARTMENT OF THE NAVY TRAFFIC ACCIDENT REPORT (CONTINUED)

NAME AND ADDRESS TELEPHONE NUMBER

W

IT

N E

S S

E S

VEHICLE DAMAGE

INSTRUCTIONS

1. In each box, circle the number of each damaged area.

2. Shade area of severest impact.

3. Draw arrow(s) to show principal direction of force.

EXAMPLE

DAMAGED VEHICLE NO. 1 DAMAGED VEHICLE NO. 2

13. HOOD

14. ROOF

15. TRUNK

16. UNDER-

CARRIAGE

17. OVER-

TURN

17. OVER-

TURN

16. UNDER-

CARRIAGE

15. TRUNK

14. ROOF

13. HOOD SKETCH DAMAGE

SEVERITY OF DAMAGE: VEHICLE NO. 1

DISABLING DAMAGE

FUNCTIONAL DAMAGE NO DAMAGE

OTHER M.V. DAMAGE

NO DAMAGE

OTHER M.V. DAMAGE

FUNCTIONAL DAMAGE

DISABLING DAMAGE

SEVERITY OF DAMAGE: VEHICLE NO. 2

NO DAMAGE

OTHER M.V. DAMAGE

FUNCTIONAL DAMAGE

DISABLING DAMAGE

SEVERITY OF DAMAGE: (OTHER VEHICLE)

TOWED BY

TO

DAMAGE TO PROPERTY (OTHER THAN VEHICLE)

TO

TOWED BY

TO

TOWED BY

*SKETCH OF COLLISION

1. Identify:

Roadway & roadway features Vehicles Pedestrians Objects on/off roadway Traffic controls Skidmarks Unusual/temperature conditions (Ice patch, construction areas, etc.)

2. Locate probable point of impact

3. Show vehicle, pedestrian or object positions at impact

4. Show probable vehicle or pedestrian paths before and after collision

DRAW ARROW SHOWING

NORTH IN CIRCLE

DESCRIPTION OF COLLISION

In Block 17, Incident/Complaint Report, (OPNAV 5527/1), indicate what probably happened before, during and after the crash, include information not on sketch, e.g., driver disability, reduced visibility, pedestrian clothing color, construction or repair work, etc.

D R

IV

E

R 'S

A C

TI

O

N B

E

F…