JC-1_ANNEX_-0200000-SectionJ-Part_II.pdf

ATTACHMENT J-0200000-05

FORMS

SEE ATTACHMENT J-0200000-05

SECTION J 0200000 N40192-19-R-9201

Transmittal Form Invoice Form Contractor Production Report Rework Items List Activity Hazard Analysis (AHA) Accident Prevention Plan Checklist Deficiency Tracking System Machinery and Mechanized Equipment Certification Certificate of Compliance Contractor Incident Report system (CIRS) OSHA Forms for Recording Work-Related Injuries and Illnesses

TRANSMITTAL FORM

CONTRACT NO.____________________________

CONTRACT TITLE ________________________________________

FROM: __________________________________________________________ _______________________________

(CONTRACTOR) (DATE)

TO: NAVFAC MARIANAS SUBMITTAL NUMBER ________________________ RESUBMITTAL OF SUBMITTAL NUMBER _________________________

SUBJ: SUBMITTAL FOR PROJECT ________________ ________________________ LINE ITEM _________________________________

IN ACCORDANCE WITH SPECIFICATIONS PARAGRAPH ____________________________.

TRANSMITTED HEREWITH ARE:

FOR: ( ) ACCEPTANCE OR APPROVAL ( ) CLARIFICATION ( ) SELECTION ( ) _________________________________________

IT IS HEREBY CERTIFIED THAT THE MATERIAL SUBMITTED HEREIN CONFORMS TO CONTRACT REQUIREMENTS AND CAN BE INSTALLED IN THE ALLOCATED

SPACES.

CONTRACTOR'S SIGNATURE __________________________________________________

FROM: _______________________________________________________________________________________________ ____________________

(SIGNATURE) (DATE)

TO: _____________________ ________________________________________________________________ FOR REVIEW AND COMMENT NO LATER

THAN ________________________. (MAXIMUM 5 WORKING DAYS)

(DATE)

FROM: _______________________________________________________________________________________________ __________________________

TO: ___________________________________ ( ) APPROVED: ( ) RETURNED FOR CORRECTION: ( ) SOURCE INSPECTION REQUIRED:

( ) APPROVED, AS NOTED: ( ) DISAPPROVED

REMARKS:

FROM: NAVFAC MARIANAS CODE ______________________________________________________________________ ___________________________

(SIGNATURE) (DATE)

TO: ___________________________________________________________________________________________________________________________________

SUBMITTAL IS: ( ) APPROVED: ( ) RETURNED FOR CORRECTION: ( ) APPROVED, AS NOTED: ( ) DISAPPROVED:

REMARKS:

NAVFACMAR__5216/7 (REV. 4__2007) (Supersedes all other revisions)

NAVFAC 7300/30 (rev 01/02)

NAVAL FACILITIES ENGINEERING COMMAND

1. CONTRACTOR'S INVOICE

From

POC/Telephone/email for this invoice:

To:

Below is a Statement of Performance under Contract Task Order # for at

The enclosure provides breakdown of this statement of performance.

A. Total value of contract/task order through change $ B. Percentage of performance complete % C. Value of completed performance $ D. Less total of prior payments $ E. Amount of this invoice $

Signature and Title:

Date:

2. FIRST ENDORSEMENT Receipt and Acceptance Certification From:

To: DFAS

1. Payment is recommended as follows:

A. Amount of work completed to (date) $ B. Less:

Retention $ Other Deductions $ $

C. Subtotal $ D. Less previous payments $ E. Certified amount for payment # on TO # $ F. Elapsed co(if applicable) G. Responsible Certifying UIC H. Invoice Receipt Date I. Material/Services Receipt Date J. Material/Services Acceptance Date K. Date forwarded to paying office L. I certify this amount is correct and payment is recommended.

Signature: Date:

Signature of Authorized Representative

Name and Title (typed):

Phone and address:

3. PROMPT PAYMENT CERTIFICATION

Signature: Date:

Signature of Authorized Representative

Name and Title (typed):

Phone and address:

Line(s) of accounting to be used for this invoice (include appropriate Line Item # (CLIN, SLIN, or ACRN, etc)

Invoice Date Invoice Number

Signature of Authorized Representative

I certify that the accounting data provided is accurate, funds have been obligated in appropriate accounting system and changes have been applied to the appropriate accounting classification reference number (ACRN), available funds have been decremented for the amount approved for disbursement and will not be de-obligated and the above invoice is correct and proper for payment.

Contract Specialist:

4296/1 (9/98) SHEET 1 OF 2

CONTRACTOR PRODUCTION REPORT

(ATTACH ADDITIONAL SHEETS IF NECESSARY)

DATE

CONTRACT NO TITLE AND LOCATION

REPORT NO

CONTRACTOR SUPERINTENDENT

AM WEATHER PM WEATHER MAX TEMP (F) MIN TEMP (F)

WORK PERFORMED TODAY

Schedule

Activity No. WORK LOCATION AND DESCRIPTION EMPLOYER NUMBER TRADE HRS

WAS A JOB SAFETY MEETING HELD THIS DATE?

(If YES attach copy of the meeting minutes) YES NO

TOTAL WORK HOURS ON JOB

SITE,

THIS DATE, INCL CON'T SHEETS JOB

SAFETY WERE THERE ANY LOST TIME ACCIDENTS THIS DATE?

(If YES attach copy of completed OSHA report) YES NO

CUMULATIVE TOTAL OF WORK

HOURS FROM PREVIOUS

REPORT WAS CRANE/MANLIFT/TRENCHING/SCAFFOLD/HV ELEC/HIGH WORK/ HAZMAT WORK DONE?

(If YES attach statement or checklist showing inspection performed.) YES NO

WAS HAZARDOUS MATERIAL/WASTE RELEASED INTO THE ENVIRONMENT?

(If YES attach description of incident and proposed action.) YES NO

TOTAL WORK HOURS FROM

START OF CONSTRUCTION

Schedule Activity No. LIST SAFETY ACTIONS TAKEN TODAY/SAFETY INSPECTIONS CONDUCTED SAFETY REQUIREMENTS HAVE BEEN MET.

EQUIPMENT/MATERIAL RECEIVED TODAY TO BE INCORPORATED IN JOB (INDICATE SCHEDULE ACTIVITY NUMBER)

Activity No. Submittal # Description of Equipment/Material Received

CONSTRUCTION AND PLANT EQUIPMENT ON JOB SITE TODAY. INDICATE HOURS USED AND SCHEDULE ACTIVITY NUMBER.

Activity No. Owner Description of Construction Equipment Used Today (incl Make and Model) Hours Used

Activity No. REMARKS

CONTRACTOR/SUPERINTENDENT DATE

4296/1 (9/98) SHEET 2 OF 2

CONTRACTOR PRODUCTION REPORT

(CONTINUATION SHEET)

DATE

CONTRACT NO TITLE AND LOCATION

REPORT NO

WORK PERFORMED TODAY

Activity No. WORK LOCATION AND DESCRIPTION EMPLOYER NUMBER TRADE HRS

Activity No. LIST SAFETY ACTIONS TAKEN TODAY/SAFETY INSPECTIONS CONDUCTED SAFETY REQUIREMENTS HAVE BEEN MET.

EQUIPMENT/MATERIAL RECEIVED TODAY TO BE INCORPORATED IN JOB (INDICATE SCHEDULE ACTIVITY NUMBER)

Activity No. Submittal # Description of Equipment/Material Received

CONSTRUCTION AND PLANT EQUIPMENT ON JOB SITE TODAY. INDICATE HOURS USED AND SCHEDULE ACTIVITY NUMBER.

Activity No. Owner Description of Construction Equipment Used Today (incl Make and Model) Hours Used

Activity No. REMARKS

INCLUDE ALL PERSONNEL WORK HOURS IN THE WORK PERFORMEDSECTIONON THIS SHEET

INTO THE FRONT CONTRACTOR PRODUCTION REPORT

CONTRACT NUMBER AND TITLE:

CONTRACTOR:

NUMBER

DATE

IDENTIFIED DESCRIPTION

CONTRACT

REQUIREMENT (Spec.

Section and Par. No., Drawing No. and Detail No., etc.)

ACTION TAKEN BY QC

MANAGER RESOLUTION

DATE

COMPLETED

REWORK ITEMS LIST

Activity/Work Task: Overall Risk Assessment Code (RAC) (Use highest code)

Project Location: Risk Assessment Code (RAC) Matrix Contract Number: Probability Date Prepared:

Severity Frequent Likely Occasional Seldom Unlikely

Catastrophic E E H H MPrepared by (Name/Title): Critical E H H M L Marginal H M M L LReviewed by (Name/Title): Negligible M L L L L

Step 1: Review each “Hazard” with identified safety “Controls” and determine RAC (See above)

“Probability” is the likelihood to cause an incident, near miss, or accident and identified as: Frequent, Likely, Occasional, Seldom or Unlikely. RAC Chart

E = Extremely High Risk“Severity” is the outcome/degree if an incident, near miss, or accident did occur and identified as: Catastrophic, Critical, Marginal, or Negligible H = High Risk

M = Moderate Risk

Notes: (Field Notes, Review Comments, etc.)

Step 2: Identify the RAC (Probability/Severity) as E, H, M, or L for each “Hazard” on AHA. Annotate the overall highest RAC at the top of AHA. L = Low Risk

Job Steps Hazards Controls RAC

Equipment to be Used Training Requirements/Competent or Qualified Personnel name(s) Inspection Requirements

Deficiency Tracking System

Date Identified Description of deficiency Name Responsible for correcting

Projected Resolution

Date

Date Actually

Resolved

Deficiency Tracking System Continued

MACHINERY & MECHANIZED EQUIPMENT INSPECTION & TESTING FORM

From: Prime Contractor: ______________________________________________________________________

Contract No.: _________________________________________________________________________________ Contract Title: ________________________________________________________________________________

To: Contracting Officer

Subj: INSPECTION & TESTING OF MACHINERY AND MECHANIZED EQUIPMENT

Reference: (a) U.S. Army Corps of Engineers, EM 385-1-1 (Series), Safety & Health Requirements Manual Per EM 385-1-1(2008), paragraph 18.G.02 - “Before any machinery or mechanized equipment is placed in use, it shall be inspected and tested in accordance with the manufacturers recommendations and requirements of this manual and shall be certified in writing by a competent person to meet the manufacturers recommendations and requirements of this manual.” This inspection & testing form shall be available upon request by the GDA. > Subsequent re-inspections will be conducted at least annually thereafter; OR

Per EM 385-1-1(2014), paragraph 18.G.02 - Before any machinery or mechanized equipment is placed in use, it shall be inspected and tested in accordance with the manufacturer’s recommendations and requirements of this manual. The Competent Person (CP) is required to sign the checklist designating that it meets the manufacturer’s recommendations and requirements of this manual. All checklists will be submitted to the GDA upon completion of the inspection and will become a part of the project file. > Subsequent re-inspections will be conducted at least annually thereafter.

Inspection and testing of machinery and mechanized equipment, as required by EM 385-1-1 (Series), has been made for the following equipment:

a. Identification of equipment:

(1) Make: _________________________________ Model: _______________________________________

License/Serial Number: _______________________________________________ Year: ________________

(2) Make: _________________________________ Model: _______________________________________

License/Serial Number: _________________________ Year: _________________________________

2. The above listed equipment is CERTIFIED TO BE IN SAFE OPERATING CONDITION BY A

COMPETENT PERSON IN ACCORDANCE WITH THE MANUFACTURE’S RECOMMENDATIONS.

Every person operating a motor vehicle, machinery and mechanized equipment, ATV, UV, or other specialty vehicles, shall possess, at all times while operating such vehicle/equipment, a license/permit (proof of qualification) valid for the equipment being operated. The operator must present the license/permit to the GDA upon request.

Failure to do so will result in the immediate prohibition of the operator to operate motor vehicles.

NOTE: Manufacture specifications or owner's manual for the equipment must be on-site.

I certify that all motor vehicle, machinery and mechanized equipment listed above are certified to be in safe operating condition in accordance with the manufacture’s recommendations.

Name, Title, and signature of Competent Person making the inspection

Name: (Competent Person)_________________________________ Title: ________________________________

Signature (Competent Person) _________________________________ Date: ____________________

Copy to: Contract File

APPENDIX P – CONTRACTOR CRANE (OR ALTERNATE MACHINE USED TO LIFT

SUSPENDED LOAD) AND RIGGING GEAR REQUIREMENTS

This certificate shall be signed by an official of the company that provides cranes (or multi-purpose machines, material handling equipment, or construction equipment used to lift loads suspended by rigging gear) or rigging gear for any application under this contract. Post a completed certificate on each crane or alternate machine (or in the contractor’s on-site office for rigging operations) brought onto Navy property.

CONTRACTING OFFICER’S POINT OF CONTACT

(Government Representative)

PHONE

PRIME CONTRACTOR/PHONE CONTRACT NUMBER

CRANE OR ALTERNATE MACHINE SUPPLIER/PHONE

(if different from prime contractor)

CRANE OR

ALTERNATE MACHINE

NUMBER (i.e., ID number)

CRANE OR ALTERNATE MACHINE MANUFACTURER/TYPE/CAPACITY

CRANE OR ALTERNATE MACHINE OPERATOR'S NAME(S)

I certify that

1. The above noted crane or alternate machine and all rigging gear conform to applicable OSHA regulations (host country regulations for naval activities in foreign countries) and applicable ASME B30 standards. The following OSHA regulations and ASME standards apply:________________________________________________________

2. The operators noted above have been trained and are qualified for the operation of the above noted crane(s) or alternate machine(s).

3. The operators noted above have been trained not to bypass safety devices during lifting operations.

4. The operators, riggers and company officials are aware of the actions required in the event of an accident as specified in the contract.

COMPANY OFFICIAL SIGNATURE DATE

COMPANY OFFICIAL NAME/TITLE

(IN CAB OR VEHICLE)

(or in the contractor’s on-site office for rigging operations)

FIGURE P-1

This checklist is based on EM 385-1-1, dated 30 November 2014. Use of this checklist is optional.

ACCIDENT PREVENTION PLAN REVIEW

Contract Number:

Contractor:

Contract Title:

Date:

Government QA:

Contractor QC:

Listed below are the minimum basic requirements for and Accident Prevention Plan, taken from Appendix A, EM 385-1-1

Yes No N/A

An Accident Prevention Plan (APP) is a safety and health policy and program document that is contract or job-specific.

The following areas are typically addressed in an APP, but besides being job-specific, the APP shall also address any unusual or unique aspects of the contract or job for which it is written. The APP shall interface with the employer’s overall safety and health program. Any portions of the overall safety and health program that are referenced in the APP shall be included as appropriate. A copy of the contractor’s project-specific, accepted APP shall be available on the work site. Each sub-contractor shall be provided a copy of the APP by the prime contractor and be required to comply with it. ANSI/ASSE A10.38 should be referenced for Programmatic Issues.

a. SIGNATURE SHEET: Title, signature, and phone numbers of the following: Yes No N/A

(1) Plan Preparer (Qualified Person (QP), Competent Person (CP), Corporate safety staff person, QC) and their qualifications;

(2) Plan must be approved by, company/corporate officers authorized to obligate the company;

(3) Plan concurrence (e.g. Chief of Operations, Corporate Chief of Safety, Corporate Industrial

Hygienist, project manager or superintendent, project safety professional, project QC). Provide concurrence of other applicable corporate and project personnel (Contractor).

b. BACKGROUND INFORMATION: List the following: Yes No N/A

(1) Contractor;

(2) Contract Number;

(3) Project Name;

(4) Brief project description, description of work to be performed, location (map), equipment to be used, anticipated high risk activities.

(5) Major phases of work anticipated.

(6) Within these major phases of work identified, activities [includes Definable features of Work

(DFOWs) and tasks] to be performed that will require an AHA shall be specifically highlighted. .

c. STATEMENT OF SAFETY AND HEALTH POLICY: Yes No N/A Provide a copy of current corporate/company Safety and Health Policy Statement, detailing commitment to providing a safe and healthful workplace for all employees. The Contractor’s written safety program goals, objectives, and accident experience goals for this contract should be provided.

d. RESPONSIBILITIES AND LINES OF AUTHORITIES: Provide the following: Yes No N/A

(1) A statement of the employer’s ultimate responsibility for the implementation of his SOH program for his own employees, all sub-contractors and all others on the worksite (includes the strict enforcement of the program.

(2) Identification and accountability of personnel responsible for safety of both corporate and project level. Contracts specifically requiring safety and industrial hygiene personnel shall include a copy of their resumes. Qualifications shall be in accordance with Section 01.A.17:

Note: Only official OSHA 30-Hour cards will be accepted or, if equivalent training is provided, appropriate instructor qualifications. See also section 01.A.17, Exception 2.

(3) If equivalent training to the OSHA 30-hour classes is being presented as qualification, the training shall have covered the following areas:

a) OSH Act/General Duty Clause;

b) 29 CFR 1904, Recordkeeping;

c) Subpart C, CC, D, E, F, K and M of OSHA;

d) Rigging, load handling equipment (LHE), welding and cutting, scaffolding, excavations, concrete and masonry, demolition; health hazards in construction, materials handling, storage and disposal, hand and power tools, motor vehicles, mechanized equipment., marine operations, steel erection, stairways and ladders, confined spaces or others that are applicable to the work being performed.

(4) The names of CPs and/or QPs and proof of competency/qualifications to meet specific OSHA CP/QP requirements must be attached. The local SOHO will review the qualifications for acceptance;

(5) Requirements and details of the employer’s Risk Management Process;

(6) Requirements for initial activity-specific AHAs to be submitted and accepted at the preparatory meetings, prior to work being performed;

(7) Requirements that no work by the Contractor shall be performed unless a designated CP/SSHO is present on the job site;

(8) Policies and procedures regarding non-compliance with safety requirements (to include disciplinary actions for violations of safety requirements) should be identified;

(9) Lines of authority;

(10) Provide written company procedures for holding managers and supervisors accountable for safety.

e. SUBCONTRACTORS AND SUPPLIERS: If applicable, provide procedures for coordinating SOH activities with other employers on the job site:

Yes No N/A

(1) Identification of subcontractors and suppliers. If not known at the time of initial APP submittal, the contractor shall include the following statement in their initial APP: “The subcontractors for the following DFOWs/activities are not known at this time, but additional information will be submitted to the APP for acceptance prior to the start of any activities listed”;

(2) Safety responsibilities of subcontractors and suppliers.

f. TRAINING: Yes No N/A

(1) Requirements for new hire SOH orientation training at the time of initial hire of each new employee.

(2) Requirements for mandatory training and certifications that are applicable to this project (e.g.

explosive actuated tools, confined space entry, crane operator, diver, vehicle operator, HAZWOPER training and certification, PPE, etc.) and any requirements for periodic retraining/recertification.

(3) Procedures for periodic safety and health training for supervisors and employees.

(4) Requirements for emergency response training.

g. SAFETY AND HEALTH INSPECTIONS: Yes No N/A

(1) Specific assignment of responsibilities for a minimum daily job site SOH inspection during periods of work activity: Who will conduct (e.g. SSHO, PM, QC, supervisors, employees – depends on level of technical proficiency needed to perform said inspections), proof of inspector’s training/qualifications, when inspections will be conducted, procedures for documentation, deficiency tracking system, and follow-up procedures;

(2) Any external inspections/certifications that may be required (e.g. USCG).

h. MISHAP REPORTING AND INVESTIGATION: The Contractor shall identify person(s) responsible to provide the following:

Yes No N/A

(1) Exposure data (man-hours worked);

(2) Mishap reports, investigations, and documentation. Report all accidents per the requirements covered in Section 01.D. Mishaps shall be reported as soon as possible, but not more than 24 hours afterwards to the KO/COR. The contractor shall report, thoroughly investigate, and analyze all mishaps occurring incidentally to an operation, project or facility for which this manual is applicable. Implement corrective actions as soon as reasonably possible and provide notice to the KO/COR when corrective actions are completed;

9. PLANS, PROGRAMS AND, PROCEDURES REQUIRED BY THE SAFETY MANUAL: Based on a risk assessment of contracted activities and on mandatory OSHA compliance programs, the Contractor shall address all applicable SOH risks and associated compliance plans. Using the EM 385-1-1 as a guide, plans, programs (assessments and evaluations) may include but not limited to:

Yes No N/A

Fatigue Management Plan (01.A.20);

Emergency Plans (01.E) Site Sanitation/Housekeeping Plan (02.B);

Medical Support Agreement (03.A.01; 03.A.03);

Blood-Borne Pathogen Program (03.A.05) Exposure Control Plan (03.A.05) Automatic External Defibrillator (AED) Program (03.B.04);

Site Layout Plan (01.A);

Access and Haul Road Plan (04.B);

Hearing Conservation Program (05.C);

Respiratory Protection Plan (05.C);

Health Hazard Control Program (06.A);

Hazard Communication Program (06.B.01);

Process Safety Management Plan (06.B.04);

Lead Compliance Plan (06.C.02 & specifications);

Asbestos Abatement Plan (06.C.03 & specifications);

Radiation Safety Program (06.F);

Abrasive Blasting Procedures (06.I.01);

Heat Stress Monitoring Plan (HSMP) (06.J.02);

Cold Stress Monitoring Plan (CSMP) (06.J.04);

Indoor Air Quality Management (06.L);

Mold Remediation Plan (06.L.04);

Chromium (VI) Exposure Evaluation (06.M);

Crystalline Silica Evaluation (06.N.02);

Lighting Plan for Night Operations (07.A.06);

Traffic Control Plan (08.C.05;

Fire Prevention Plan (09.A.01);

Wild Land Fire Management Plan (09.L);

Arc Flash Hazard Analysis (11.B);

Assured Equipment Grounding Control Program (AEGCP) (11.D.05, Appendix E);

Hazardous Energy Control Program and Procedures (12.A.01);

Standard Pre-Lift Plan – Load Handling Equipment (16.A.03);

Critical Lift Plan – Load Handling Equipment (16.H);

Naval Architectural Analysis – Load Handling Equipment (Floating)(16.L);

Floating Plant Inspection and Certification (19.A.01);

Severe Weather Plan for Marine Activities (19.A.04);

Emergency Plan for Marine Activities (19.A.04);

Man Overboard/Abandon Ship Procedures (19.A.04);

Float Plan for Launches, Motorboats, and Skiffs (19.F.04);

Fall Protection & Prevention Plan (21.D);

Demolition/Renovation Plan (to include engineering survey) (23.A);

Rope Access Work Plan (24.H);

Excavation/Trenching Plan (25.A.01);

Fire Prevention and Protection Plan for Underground Construction (26.D.01) Compressed Air Work Plan for Underground Construction (26.I.01);

Erection and Removal Plan for Formwork and Shoring (27.C);

Precast Concrete Plan (27.D.01);

Lift Slab Plans (27.E);

Masonry Bracing Plan (27.E.01);

Steel Erection Plan (28.B);

Explosives Safety Site Plan (ESSP) (29.A);

Blasting Plan (29.A; 26.J);

Diving Operations Plan (30.A.14, 30.A.16);

Safe Practices Manual for Diving Activities (30.A.15);

Emergency Management Plan for Diving (30.A.18);

Tree Felling and Maintenance Program (31.A.01) Aircraft/Airfield Construction Safety & Phasing Plan (CSPP) (32.A.02;

Aircraft/Airfield Safety Plan Compliance Document (SPCD) (32.A.02;

Site Safety and Health Plan for HTRW (33.B);

Confined Space Entry Procedures (34.A.05);

Confine Space Program (34.A.06)

10. RISK MANAGEMENT PROCESSES (AHAs): Detailed project-specific hazards and controls shall be provided by an (AHA) for each activity (DFOW).

Yes No N/A

REMARKS:

OSHA

Forms for Recording

Work-Related Injuries and Illnesses

What’s Inside...

In this package, you’ll find everything you need to complete OSHA’s Log and the Summary of Work-Related Injuries and Illnesses for the next several years. On the following pages, you’ll find:

An Overview: Recording Work-Related Injuries and Illnesses — General instructions for filling out the forms in this package and definitions of terms you should use when you classify your cases as injuries or illnesses.

How to Fill Out the Log — An example to guide you in filling out the Log properly.

Log of Work-Related Injuries and

Illnesses — Several pages of the Log (but you may make as many copies of the Log as you need.) Notice that the Log is separate from the Summary.

Summary of Work-Related Injuries and Illnesses — Removable Summary pages for easy posting at the end of the year. Note that you post the Summary only, not the Log.

Worksheet to Help You Fill Out the Summary — A worksheet for figuring the average number of employees who worked for your establishment and the total number of hours worked.

OSHA’s 301: Injury and Illness

Incident Report — A copy of the OSHA 301 to provide details about the incident.

You may make as many copies as you need or use an equivalent form.

Take a few minutes to review this package. If you have any questions, visit us online at www.osha.gov or call your local OSHA office.

We’ll be happy to help you.

U .S

D e p a rt m e n t o f

L a b o r O c c u p a ti o n a l

S a fe ty a n d H e a lt h

A d m in is tr a ti o n

Dear Employer:

This booklet includes the forms needed for maintaining occupational injury and illness records. Many but not all employers must complete the OSHA injury and illness recordkeeping forms on an ongoing basis. Employers in State Plan States should check with their State Plan to see if the exemptions below apply.

Employers with 10 or fewer employees throughout the previous calendar year do not need to complete these forms. Said another way, if there are more than 10 employees at any time during that calendar year, the employer may come under the requirement. When counting employees, you must include full-time, part-time, temporary, and seasonal workers. This exemption is based on the employment of the entire company rather than the establishment. For example, if a company has two establishments, one with 5 employees and one with 7 employees, the company must fill out the forms for each establishment because the company employment is greater than 10.

In addition to the small employer exemption, there is an exemption for establishments classified in certain industries. For example, the forms do not need to be completed for restaurants, banks, and medical offices. A complete list of exempt industries can be found on the OSHA web page at www.osha.gov.

Establishments normally exempt from keeping the OSHA forms must complete the forms if they are informed in writing to do so by the Bureau of Labor Statistics or OSHA. Also, exempt establishments must report to the local OSHA office within 8 hours any fatality or incident involving three or more in-patient hospitalizations.

The Occupational Safety and Health Administration shares with you the goal of preventing injuries and illnesses in our nation’s workplaces.

Accurate injury and illness records will help us achieve that goal.

Occupational Safety and Health Administration U.S. Department of Labor

The Log of Work-Related Injuries and Illnesses (Form 300) is used to classify work-related injuries and illnesses and to note the extent and severity of each case. When an incident occurs, use the Log to record specific details about what happened and how it happened. The Summary — a separate form (Form 300A) — shows the totals for the year in each category. At the end of the year, post the Summary in a visible location so that your employees are aware of the injuries and illnesses occurring in their workplace.

Employers must keep a Log for each establishment or site. If you have more than one establishment, you must keep a separate Log and Summary for each physical location that is expected to be in operation for one year or longer.

Note that your employees have the right to review your injury and illness records. For more information, see 29 Code of Federal Regulations Part 1904.35, Employee Involvement.

Cases listed on the Log of Work-Related Injuries and Illnesses are not necessarily eligible for workers’ compensation or other insurance benefits. Listing a case on the Log does not mean that the employer or worker was at fault or that an OSHA standard was violated.

When is an injury or illness considered work-related?

An injury or illness is considered work-related if an event or exposure in the work environment caused or contributed to the condition or significantly aggravated a preexisting condition. Work-relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the workplace, unless an exception specifically applies. See 29 CFR Part 1904.5(b)(2) for the exceptions. The work environment includes the establishment and other locations where one or more employees are working or are present as a condition of their employment. See 29 CFR Part 1904.5(b)(1).

Which work-related injuries and illnesses should you record?

Record those work-related injuries and illnesses that result in:

death, loss of consciousness, days away from work, restricted work activity or job transfer, or medical treatment beyond first aid.

You must also record work-related injuries and illnesses that are significant (as defined below) or meet any of the additional criteria listed below.

You must record any significant work-related injury or illness that is diagnosed by a physician or other licensed health care professional. You must record any work-related case involving cancer, chronic irreversible disease, a fractured or cracked bone, or a punctured eardrum. See 29 CFR 1904.7.

What are the additional criteria?

You must record the following conditions when they are work-related:

any needlestick injury or cut from a sharp object that is contaminated with another person’s blood or other potentially infectious material;

any case requiring an employee to be medically removed under the requirements of an OSHA health standard;

tuberculosis infection as evidenced by a positive skin test or diagnosis by a physician or other licensed health care professional after exposure to a known case of active tuberculosis;

an employee's hearing test (audiogram) reveals 1) that the employee has experienced a Standard Threshold Shift (STS) in hearing in one or both ears (averaged at 2000, 3000, and 4000 Hz) and 2) the employee's total hearing level is 25 decibels (dB) or more above audiometric zero ( also averaged at 2000, 3000, and 4000 Hz) in the same ear(s) as the STS.

What is medical treatment?

Medical treatment includes managing and caring for a patient for the purpose of combating disease or disorder. The following are not considered medical treatments and are NOT recordable:

visits to a doctor or health care professional solely for observation or counseling;

What do you need to do?

1. Within 7 calendar days after you receive information about a case, decide if the case is recordable under the OSHA recordkeeping requirements.

2. Determine whether the incident is a new case or a recurrence of an existing one.

3. Establish whether the case was work-related.

4. If the case is recordable, decide which form you will fill out as the injury and illness incident report.

You may use OSHA’s 301: Injury and Illness Incident Report or an equivalent form. Some state workers compensation, insurance, or other reports may be acceptable substitutes, as long as they provide the same information as the OSHA 301.

How to work with the Log

The Occupational Safety and Health (OSH) Act of 1970 requires certain employers to prepare and maintain records of work-related injuries and illnesses. Use these definitions when you classify cases on the Log. OSHA’s recordkeeping regulation (see 29 CFR Part 1904) provides more information about the definitions below.

1. Identify the employee involved unless it is a privacy concern case as described below.

2. Identify when and where the case occurred.

3. Describe the case, as specifically as you can.

4. Classify the seriousness of the case by recording the associated with the case, with column G (Death) being the most serious and column J (Other recordable cases) being the least serious.

5. Identify whether the case is an injury or illness. If the case is an injury, check the injury category. If the case is an illness, check the appropriate illness category.

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An Overview:

Recording Work-Related Injuries and Illnesses diagnostic procedures, including administering prescription medications that are used solely for diagnostic purposes; and any procedure that can be labeled first aid. (See below for more information about first aid.)

What is first aid?

If the incident required only the following types of treatment, consider it first aid. Do NOT record the case if it involves only:

using non-prescription medications at non-prescription strength;

administering tetanus immunizations;

cleaning, flushing, or soaking wounds on the skin surface;

using wound coverings, such as bandages, BandAids™, gauze pads, etc., or using SteriStrips™ or butterfly bandages;

using hot or cold therapy;

using any totally non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc.;

using temporary immobilization devices while transporting an accident victim (splints, slings, neck collars, or back boards);

drilling a fingernail or toenail to relieve pressure, or draining fluids from blisters;

using eye patches;

using simple irrigation or a cotton swab to remove foreign bodies not embedded in or adhered to the eye;

using irrigation, tweezers, cotton swab or other simple means to remove splinters or foreign material from areas other than the eye;

injury or illness, but you do not need to include details of an intimate or private nature.

What if the outcome changes after you record the case?

If the outcome or extent of an injury or illness changes after you have recorded the case, simply draw a line through the original entry or, if you wish, delete or white-out the original entry. Then write the new entry where it belongs. Remember, you need to record the most serious outcome for each case.

Classifying injuries

An injury is any wound or damage to the body resulting from an event in the work environment.

Examples: Cut, puncture, laceration, abrasion, fracture, bruise, contusion, chipped tooth, amputation, insect bite, electrocution, or a thermal, chemical, electrical, or radiation burn. Sprain and strain injuries to muscles, joints, and connective tissues are classified as injuries when they result from a slip, trip, fall or other similar accidents.

Under what circumstances should you NOT enter the employee’s name on the OSHA Form 300?

You must consider the following types of injuries or illnesses to be privacy concern cases:

an injury or illness to an intimate body part or to the reproductive system, an injury or illness resulting from a sexual assault, a mental illness, a case of HIV infection, hepatitis, or tuberculosis, a needlestick injury or cut from a sharp object that is contaminated with blood or other potentially infectious material (see 29 CFR Part

1904.8 for definition), and other illnesses, if the employee independently and voluntarily requests that his or her name not be entered on the log.

You must not enter the employee’s name on the OSHA 300 Log for these cases. Instead, enter “privacy case” in the space normally used for the employee’s name. You must keep a separate, confidential list of the case numbers and employee names for the establishment’s privacy concern cases so that you can update the cases and provide information to the government if asked to do so.

If you have a reasonable basis to believe that information describing the privacy concern case may be personally identifiable even though the employee’s name has been omitted, you may use discretion in describing the injury or illness on both the OSHA 300 and 301 forms. You must enter enough information to identify the cause of the incident and the general severity of the using finger guards;

using massages;

drinking fluids to relieve heat stress.

How do you decide if the case involved restricted work?

Restricted work activity occurs when, as the result of a work-related injury or illness, an employer or health care professional keeps, or recommends keeping, an employee from doing the routine functions of his or her job or from working the full workday that the employee would have been scheduled to work before the injury or illness occurred.

How do you count the number of days of restricted work activity or the number of days away from work?

Count the number of calendar days the employee was on restricted work activity or was away from work as a result of the recordable injury or illness.

Do not count the day on which the injury or illness occurred in this number. Begin counting days from the day the incident occurs. If a single injury or illness involved both days away from work and days of restricted work activity, enter the total number of days for each. You may stop counting days of restricted work activity or days away from work once the total of either or the combination of both reaches 180 days.

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Classifying illnesses

Skin diseases or disorders Skin diseases or disorders are illnesses involving the worker’s skin that are caused by work exposure to chemicals, plants, or other substances.

Examples: Contact dermatitis, eczema, or rash caused by primary irritants and sensitizers or poisonous plants; oil acne; friction blisters, chrome ulcers; inflammation of the skin.

Respiratory conditions Respiratory conditions are illnesses associated with breathing hazardous biological agents, chemicals, dust, gases, vapors, or fumes at work.

Examples: Silicosis, asbestosis, pneumonitis, pharyngitis, rhinitis or acute congestion;

farmer’s lung, beryllium disease, tuberculosis, occupational asthma, reactive airways dysfunction syndrome (RADS), chronic obstructive pulmonary disease (COPD), hypersensitivity pneumonitis, toxic inhalation injury, such as metal fume fever, chronic obstructive bronchitis, and other pneumoconioses.

Poisoning Poisoning includes disorders evidenced by abnormal concentrations of toxic substances in blood, other tissues, other bodily fluids, or the breath that are caused by the ingestion or absorption of toxic substances into the body.

Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals; poisoning by carbon monoxide, hydrogen sulfide, or other gases; poisoning by benzene, benzol, carbon tetrachloride, or other organic solvents;

poisoning by insecticide sprays, such as parathion or lead arsenate; poisoning by other chemicals, such as formaldehyde.

Hearing Loss Noise-induced hearing loss is defined for recordkeeping purposes as a change in hearing threshold relative to the baseline audiogram of an average of 10 dB or more in either ear at 2000, 3000 and 4000 hertz, and the employee’s total hearing level is 25 decibels (dB) or more above audiometric zero (also averaged at 2000, 3000, and 4000 hertz) in the same ear(s).

All other illnesses All other occupational illnesses.

Examples: Heatstroke, sunstroke, heat exhaustion, heat stress and other effects of environmental heat; freezing, frostbite, and other effects of exposure to low temperatures;

decompression sickness; effects of ionizing radiation (isotopes, x-rays, radium); effects of nonionizing radiation (welding flash, ultra-violet rays, lasers); anthrax; bloodborne pathogenic diseases, such as AIDS, HIV, hepatitis B or hepatitis C; brucellosis; malignant or benign tumors; histoplasmosis; coccidioidomycosis.

When must you post the Summary?

You must post the Summary only — not the Log — by February 1 of the year following the year covered by the form and keep it posted until April 30 of that year.

How long must you keep the Log and Summary on file?

You must keep the Log and Summary for 5 years following the year to which they pertain.

Do you have to send these forms to OSHA at the end of the year?

No. You do not have to send the completed forms to OSHA unless specifically asked to do so.

How can we help you?

If you have a question about how to fill out the Log, visit us online at www.osha.gov or call your local OSHA office.

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What is an incidence rate?

An incidence rate is the number of recordable injuries and illnesses occurring among a given number of full-time workers (usually 100 full-time workers) over a given period of time (usually one year). To evaluate your firm’s injury and illness experience over time or to compare your firm’s experience with that of your industry as a whole, you need to compute your incidence rate. Because a specific number of workers and a specific period of time are involved, these rates can help you identify problems in your workplace and/or progress you may have made in preventing work-related injuries and illnesses.

How do you calculate an incidence rate?

You can compute an occupational injury and illness incidence rate for all recordable cases or for cases that involved days away from work for your firm quickly and easily. The formula requires that you follow instructions in paragraph

(a) below for the total recordable cases or those in paragraph (b) for cases that involved days away from work, and for both rates the instructions in paragraph (c).

(a) To find out the total number of recordable injuries and illnesses that occurred during the year, count the number of line entries on your OSHA Form 300, or refer to the OSHA Form 300A and sum the entries for columns (G), (H), (I), and (J).

(b) To find out the number of injuries and illnesses that involved days away from work, count the number of line entries on your OSHA Form 300 that received a check mark in column (H), or refer to the entry for column (H) on the OSHA Form 300A.

(c) The number of hours all employees actually worked during the year. Refer to OSHA Form 300A and optional worksheet to calculate this number.

You can compute the incidence rate for all recordable cases of injuries and illnesses using the following formula:

Total number of injuries and illnesses X 200,000 ÷ Number of hours worked by all employees = Total recordable case rate

(The 200,000 figure in the formula represents the number of hours 100 employees working 40 hours per week, 50 weeks per year would work, and provides the standard base for calculating incidence rates.)

You can compute the incidence rate for recordable cases involving days away from work, days of restricted work activity or job transfer (DART) using the following formula:

(Number of entries in column H + Number of entries in column I) X 200,000 ÷ Number of hours worked by all employees = DART incidence rate

You can use the same formula to calculate incidence rates for other variables such as cases involving restricted work activity (column (I) on Form 300A), cases involving skin disorders (column (M-2) on Form 300A), etc. Just substitute the appropriate total for these cases, from Form 300A, into the formula in place of the total number of injuries and illnesses.

What can I compare my incidence rate to?

The Bureau of Labor Statistics (BLS) conducts a survey of occupational injuries and illnesses each year and publishes incidence rate data by various classifications (e.g., by industry, by employer size, etc.). You can obtain these published data at www.bls.gov/iif or by calling a BLS Regional Office.

Optional

Calculating Injury and Illness Incidence Rates

Worksheet

Number of entries in Column H Column I

DART incidence rate

Total number of injuries and illnesses

X 200,000

Total recordable case rate

X 200,000

Number of hours worked by all employees

Number of hours worked by all employees

Note: You can type input into this form and save it.

Because the forms in this recordkeeping package are “fillable/writable” PDF documents, you can type into the input form fields and then save your inputs using the free Adobe PDF Reader. In addition, the forms are programmed to auto-calculate as appropriate.

ResetSave Input

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How to Fill Out the Log The Log of Work-Related Injuries and Illnesses is used to classify work-related injuries and illnesses and to note the extent and severity of each case. When an incident occurs, use the Log to record specific details about what happened and how it happened.

If your company has more than one establishment or site, you must keep separate records for each physical location that is expected to remain in operation for one year or longer.

If you need additional copies of the Log, you may photocopy the printout or insert additional form pages in the PDF, and then use as many as you need.

The Summary — a separate form — shows the work-related injury and illness totals for the year in each category. At the end of the year, count the number of incidents in each category and transfer the totals from the Log to the Summary. Then post the Summary in a visible location so that your employees are aware of injuries and illnesses occurring in their workplace.

You don’t post the Log. You post only the Summary at the end of the year.

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Note: Because the forms in this recordkeeping package are “fillable/ writable” PDF documents, you can type into the input form fields and then save your inputs using the free Adobe PDF Reader. In addition, the forms are programmed to auto-calculate as appropriate.

month / day daysdays Reset month / day daysdays Reset month / day daysdays Reset month / day daysdays Reset month / day / daysdays

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U.S. Department of Labor Occupational Safety and Health Administration

OSHA’s Form 300 (Rev. 01/2004)

Year 20Log of Work-Related Injuries and Illnesses You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you’re not sure whether a case is recordable, call your local OSHA office for help.

Page

In ju ry

Sk in d is or de r

R es pi ra to ry co nd iti on

Page totals

Establishment name

City

Enter the number of days the injured or ill worker was:

Select the “Injury” column or choose one type of illness:

Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

(A) (B) (C) (D) (E) (F)

(M)

(K) (L)(G) (H) (I) (J) Death

Days away from work

On job transfer or restriction

Away from work

Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.

SELECT ONLY ONE box for each case based on the most serious outcome for that case:

Job transfer or restriction

Other record-able cases

Remained at Work

(1) (2) (3) (4) (5) (6)

(1) (2) (3) (4) (5) (6)

(e.g., Welder) (e.g., Loading dock north end) e.g., Second degree burns on right forearm from acetylene torch)

(e.g., 2/10)

Identify the person Describe the case Classify the case

Po is on in g

H ea rin g lo ss

A ll ot he r ill ne ss es A ll ot he r ill ne ss es

H ea rin g lo ss

Po is on in g

R es pi ra to ry co nd iti on

Sk in d is or de r

In ju ry

Form approved OMB no. 1218-0176

State of

Note: You can type input into this form and save it.

Because the forms in this recordkeeping package are “fillable/writable” PDF documents, you can type into the input form fields and then save your inputs using the free Adobe PDF Reader. In addition, the forms are programmed to auto-calculate as appropriate.

1 1Save Input Add a Form Page

OSHA’s Form 300A (Rev. 01/2004)

Summary of Work-Related Injuries and Illnesses Form approved OMB no. 1218-0176

Total number of deaths

Total number of cases with days away from work

Number of Cases

Total number of days away from work

Total number of days of job transfer or restriction

Number of Days

Post this Summary page from February 1 to April 30 of the year following the year covered by the form.

All establishments covered by Part 1904 must complete this Summary page, even if no work-related injuries or illnesses occurred during the year.

Remember to review the Log to verify that the entries are complete and accurate before completing this summary.

Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you've added the entries from every page of the Log. If you had no cases, write “0.”

Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or its equivalent. See 29 CFR Part 1904.35, in OSHA’s recordkeeping rule, for further details on the access provisions for these forms.

Establishment information

Your establishment name

Street

City

Industry description (e.g., Manufacture of motor truck trailers)

Standard Industrial Classification (SIC), if known (e.g.,…