Attachment J-0200000-05 Forms.pdf

J-0200000-05

CONTRACT FORMS

1. Transmittal Form

2. Invoice Form

3. Contractor Production Report

4. Rework Items List

5. Activity Hazard Analysis (AHA)

6. Accident Prevention Plan Checklist

7. Deficiency Tracking System

8. Machinery and Mechanized Equipment Certification

9. Certificate of Compliance

10. Contractor Incident Report system (CIRS)

11. 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

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)

Submittal # Description of Equipment/Material Received

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

Owner Description of Construction Equipment Used Today (incl Make and Model) Hours Used

REMARKS

CONTRACTOR/SUPERINTENDENT DATE

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

CONTRACTOR PRODUCTION REPORT

(CONTINUATION SHEET)

CONTRACT NO TITLE AND LOCATION

REPORT NO

WORK PERFORMED TODAY

Schedule

WORK LOCATION AND DESCRIPTION EMPLOYER NUMBER TRADE HRS

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)

Submittal # Description of Equipment/Material Received

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

Owner Description of Construction Equipment Used Today (incl Make and Model) Hours Used

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 Hazard Analysis (AHA) 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 M Prepared by (Name/Title):

Critical E H H M L Marginal H M M L L

Reviewed 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

JMH 2009

Accident Prevention Plans (APP) Appendix A EM 385-1-1

(15 SEPTEMBER 2008 edition)

FEAD/ROICC/FSC/OICC offices with the new safety requirements of EM 385 dated 15 SEPTEMBER 2008 assist our Contractors in learning how to properly develop an Accident Prevention Plan which will meet the US Army Corps of Engineers Safety and Health Requirements Manual EM 385-1-1 15 September 2008 Appendix A requirements as a minimum plan. Many of the Accident Prevention Plans (APP) that have been submitted/accepted are not in the correct format or do not address all the requirements of Appendix A.

Special new note For LIMITED-SCOPE SERVICE, SUPPLY AND R&D CONTRACTS, for example, mowing (only), park attendant, rest room cleaning, the Contracting Officer and SOHO may allow an ABBREVIATED APP (customized APP requirements and waive the more stringent elements of this section). See 01.A.11 and Appendix A, paragraph 11.

An Accident Prevention Plan (APP) is a safety and health policy and program document. APP shall be job-specific and shall also address any unusual or unique aspects of the project or activity for which it is written. The APP shall interface with the employer’s overall safety and health program, and a copy shall be available on the work site. Any portions of the overall safety and health program that are referenced in the APP shall be included as appropriate.

ANSI/ASSE A10.38 should be referenced for Programmatic Issues.

Most contracts awarded within NAVFAC are under the guidelines of the EM 385-1-1 concerning contract safety requirements. All NAVFAC FEAD/ROICC/OICC/FSC contractors will adhere to the EM 385-1-1 requirements for Accident Prevention Plans. The APP shall be developed by qualified personnel and then signed in accordance with Appendix A, paragraph 1. The Contractor shall be responsible for documenting the Qualified person’s credentials.

“Qualified person: one who, by possession of a recognized degree, certificate, or professional standing, or extensive knowledge, training, and experience, has successfully demonstrated his/her ability to solve or resolve problems related to the subject matter, the work, or the project.”

The Contractor shall address each of the elements/sub-elements in the outline contained in Appendix A in the order that they are provided in the manual. If an item is not applicable because of the nature of the work to be performed, the Contractor shall state this exception and provide a justification. > See Appendix A.

Accident Prevention Plans that are submitted shall follow the guidelines of Appendix A of the EM 385-1-1 or they will found not acceptable and sent back to the contractor for re-submittal. The contractor can not start work on a contract until the Accident Prevention Plan has been submitted and found acceptable. A copy shall be available on the work site. The APP shall be written in English by the Prime Contractor and shall articulate the specific work and hazards pertaining to the contract.

The APP shall contain appropriate appendices (for example, a SSHP for hazardous waste site cleanup operations, a Lead Compliance Plan when working with lead, or an Asbestos Hazard Abatement Plan when working with asbestos). The APP shall also implement in detail the pertinent requirements of this manual. Before initiation of work at the job site, an APP shall be reviewed and found acceptable by the GDA.

“Accepted/Acceptable: a term denoting when a written procedure, practice, method, program, engineering design, or employee qualification criteria submittal, which, after a cursory review by a GDA, is determined to generally conform to safety and health or contractual requirements.

Acceptance or acceptability of such submittals in no way relieves the submitting entity from \ensuring employees a safe and healthful work environment or complying with all contractual requirements and good engineering practices.”

For contract operations, the Contractor's APP shall be job specific and should include work to be performed by subcontractors.

In addition, the APP should state measures to be taken by the Contractor to control hazards associated with materials, services, or equipment provided by suppliers.

Updates to the APP shall be reviewed and approved by the GDA

“Approved: a method, equipment, procedure, practice, tool, etc., that is sanctioned, confirmed, as acceptable for a particular use or purpose by a person or organization authorized to render such approval or judgment.”

Steps for putting the Accident Prevention Plan Together.

1. You will need a three ring binder that will contain your Accident Prevention Plan.

2. You will need tab sheets numbered 1 through 10. The tab sheets will be used to separate the 10 sections shown in Appendix A.

3. You will need to have an index page installed as the first page of your plan.

4. Next insert tab sheet number one.

5. Next comply with section #1 a. b. and c. When you have completed these items insert them into your tab # 1 section.

6. Next insert tab sheet number two.

7. Next comply with section #2 a. b. c. d. When you have completed these items insert them into your tab #2 section

8. By now as you can see each tab section has sub statements within them that will be inserted into each section. Follow this procedure until all 10 sections are completed. Upon completion put together the correct number of Accident Prevention Plans required by your contract to be submitted to the and forward the copies to the Office in Charge of Construction.

By complying with Appendix A of the EM 385-1-1 you will have an Accident Prevention Plan which will meet the requirements of your contract and the Accident Prevention Plan can be modified for reuse with other NAVFAC contracts which may be awarded to your company

YES NO N/A

1. SIGNATURE SHEET. Title, signature, and phone number of the following:

a. Plan preparer (Qualified Person, Competent Person, such as corporate safety staff person, QC);

b. Plan must be approved, by company/corporate officers authorized to obligate the company;

c. 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).

2. BACKGROUND INFORMATION. List the following:

a. Contractor;

b. Contract number;

c. Project name;

d. Brief project description, description of work to be performed, and location; phases of work anticipated (these will require an AHA).

3. STATEMENT OF SAFETY AND HEALTH POLICY.

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.

4. RESPONSIBILITIES AND LINES OF AUTHORITIES. Provide the following:

a. A statement of the employer’s ultimate responsibility for the implementation of his SOH program;

b. Identification and accountability of personnel responsible for safety at both corporate and project level. Contracts specifically requiring safety or industrial hygiene personnel shall include a copy of their resumes.

Qualifications shall include the OSHA 30-hour course or equivalent course areas as listed here:

(1) OSH Act/General Duty Clause;

(2) 29 CFR 1904, Recordkeeping;

(3) Subpart C: General Safety and Health Provisions, Competent Person;

(4) Subpart D: Occupational Health and Environmental Controls, Citations and Safety Programs;

(5) Subpart E: PPE, types and requirements for use;

(6) Subpart F: understanding fire protection in the workplace;

(7) Subpart K: Electrical;

(8 Subpart M: Fall Protection;

(9) Rigging, 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 any others that are applicable to the work being performed.

c. The names of Competent and/or Qualified Person(s) and proof of competency/qualification to meet specific OSHA Competent/Qualified Person(s) requirements must be attached. The District SOHO will review the qualifications for acceptance;

d. Requirements that no work shall be performed unless a designated competent person is present on the job site;

e. Requirements for pre-task safety and health analysis;

f. Lines of authority;

g. Policies and procedures regarding noncompliance with safety requirements (to include disciplinary actions for violation of safety requirements) should be identified;

h. Provide written company procedures for holding managers and supervisors accountable for safety.

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

a. Identification of subcontractors and suppliers (if known);

b. Safety responsibilities of subcontractors and suppliers.

6. TRAINING.

a. Requirements for new hire SOH orientation training at the time of initial hire of each new employee.

b. 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) and any requirements for periodic retraining/recertification.

c. Procedures for periodic safety and health training for supervisors and employees.

d. Requirements for emergency response training.

> See paragraph 9.b. below for a list of requirements that may require emergency response training.

7. SAFETY AND HEALTH INSPECTIONS.

a. Specific assignment of responsibilities for a minimum daily job site safety and health inspection during periods of work activity:

Who will conduct (e.g., SSHO, PM, safety professional, 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;

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

8. ACCIDENT REPORTING. The Contractor shall identify person(s) responsible to provide the following:

a. Exposure data (man-hours worked);

b. Accident investigations, reports, and logs: Report all accidents as soon as possible but not more than 24 hours afterwards to the Contracting Officer/Representative (CO/COR). The contractor shall thoroughly investigate the accident and submit the findings of the investigation along with appropriate corrective actions to the CO/COR in the prescribed format as soon as possible but no later than five (5) working days following the accident. Implement corrective actions as soon as reasonably possible;

c. The following require immediate accident notification:

(1) A fatal injury;

(2) A permanent total disability;

(3) A permanent partial disability;

(4) The hospitalization of three or more people resulting from a single occurrence;

(5) Property damage of $200,000 or more.

9. PLANS (PROGRAMS, 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 occupational risks and compliance plans. Using the EM 385- 1-1 as a guide, plans may include but not be limited to:

a. Layout plans (04.A.01);

b. Emergency response plans:

(1) Procedures and tests (01.E.01);

(2) Spill plans (01.E.01, 06.A.02);

(3) Firefighting plan (01.E.01, Section 19);

(4) Posting of emergency telephone numbers (01.E.05);

(5) Man overboard/abandon ship (Section19.A.04);

(6) Medical Support. Outline on-site medical support and off-site medical arrangements including rescue and medical duties for those employees who are to perform them, and the name(s) of on-site Contractor personnel trained in first aid and CPR. A minimum of two employees shall be certified in CPR and first-aid per shift/site (Section 03.A.02; 03.D);

c. Plan for prevention of alcohol and drug abuse (01.C.02);

d. Site sanitation plan (Section 02);

e. Access and haul road plan (4.B);

f. Respiratory protection plan (05.G);

g. Health hazard control program (06.A);

h. Hazard communication program (06.B.01);

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

j. Lead abatement plan (06.B.05 & specifications);

k. Asbestos abatement plan (06.B.05 & specifications);

l. Radiation Safety Program (06.E.03.a);

m. Abrasive blasting (06.H.01);

n. Heat/Cold Stress Monitoring Plan (06.I.02)

o. Crystalline Silica Monitoring Plan (Assessment) (06.M) ;

p. Night operations lighting plan (07.A.08);

q. Fire Prevention Plan (09.A);

r. Wild Land Fire Management Plan (09.K);

s. Hazardous energy control plan (12.A.01);

t. Critical lift Plan (16.H);

u. Contingency plan for severe weather (19.A.03);

v. Float Plan (19.F.04);

w. Site-Specific Fall Protection & Prevention Plan (21.C);

x. Demolition plan (to include engineering survey) (23.A.01);

y. Excavation/trenching plan (25.A.01);

z. Emergency rescue (tunneling) (26.A.);

aa. Underground construction fire prevention and protection plan (26.D.01);

bb. Compressed air plan (26.I.01);

cc. Formwork and shoring erection and removal plans (27.C);

dd. Pre-Cast Concrete Plan (27.D);

ee. Lift slab plans (27.E);

ff. Steel erection plan (27.F.01);

gg. Site Safety and Health Plan for HTRW work (28.B);

hh. Blasting Safety Plan (29.A.01);

ii. Diving plan (30.A.13);

jj. Confined space Program (34.A);

9. RISK MANAGEMENT PROCESSES. Detailed project-specific hazards and controls shall be provided by an Activity Hazard Analysis (0I.A.13) for each major phase/activity of work.

REMARKS;

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 CERTIFICATION FORM

From (Prime Contractor): ______________________________________________________________________

Contract No.: _________________________________________________________________________________

Contract Title: ________________________________________________________________________________

To: Contracting Officer

Subj: SAFETY CERTIFICATION OF MACHINERY AND MECHANIZED EQUIPMENT

Reference: (a) U.S. Army Corps of Engineers, EM 385-1-1 (15 Sep 2008), Safety & Health Requirements Manual,

(b) NAVFAC P-307 (Dec 2009)

Per EM 385-1-1, paragraph 18.A.03.b, “Before initial use, vehicles not otherwise inspected by State or local authorities, shall be inspected by a qualified mechanic and found in safe operating condition and in compliance with all required published vehicle safety standards. This safety certification form shall be available for inspection on the work site. > Subsequent re-inspections will be conducted at least annually thereafter.

Inspection and certification of machinery and mechanized equipment, as required by EM 385-1-1 and NAVFAC P- 307, 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

QUALIFIED PERSON IN ACCORDANCE WITH THE MANUFACTURE’S RECOMMENDATIONS.

Every person operating a motor vehicle shall possess, at all times while operating such vehicle, a license/permit valid for the equipment being operated. All machinery and mechanized equipment will be operated only by designated qualified personnel.

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

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

Name: ________________________________________ Title: ________________________________

Signature (Qualified Person) _________________________________ Date: ____________________

Copy to: Contract File

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

SUSPENDED LOAD) AND RIGGING GEAR REQUIREMENTS

CERTIFICATE OF COMPLIANCE

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

COMPANY OFFICIAL NAME/TITLE

POST ON CRANE (OR ALTERNATE MACHINE)

(IN CAB OR VEHICLE)

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

FIGURE P-1

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 most serious outcome 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 after 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.

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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

S ki n di so rd er

R es pi ra to ry co nd it io n

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…