N6945023Q0003_PWS_Attachments.pdf

Section J - 0200000 Management and Administration

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Naval Air Station Pensacola, Florida

Section J – 0200000 Management and Administration

Attachment Number Attachment Title J-0200000-01 Definitions and Acronyms J-0200000-02 Directives, Instructions, and References J-0200000-03 Forms J-0200000-04 Contractor Hazardous Material Inventory Log J-0200000-05 Commander Navy Region Southeast Instruction 4101.1C J-0200000-06 Exhibit Line Item Numbers (ELINs)

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Attachment J-0200000-01 Definitions and Acronyms

Definition Description Assessment A general term referring to either a survey or inspection of a facility to determine condition.

Asset A general term used to refer to an item, such as a component, system, building or facility, which is managed by an automated data management program.

Competent Person A person who has the professional experience and training necessary to identify existing and predictable hazards at a work or service environment, and who has the authority to take prompt and corrective action to eliminate or remove dangers from the environment.

One who can identify existing and predictable hazards in the working environment or working conditions that are dangerous to personnel and who has authorization to take prompt corrective measures to eliminate them.

Component Inventory Management Unit

(CIMU)

An organization of like-kind real property into manageable maintenance units. CIMU is a building component, group of components or component assemblies, serving a specific purpose in a facility that can be expected to follow a common and predictable lifecycle behavior. This class of non-equipment will include items such as exterior walls, exterior windows, interior finish, and roofs. This class of equipment will include items such as fan coil units, air handling units, lighting, and water closets. CIMUs can include one or more items of installed equipment typically subject to routine scheduled maintenance.

Confined Work Space A space that is large enough and so configured that a person may bodily enter a space (such as in tanks, vessels, silos, storage bins, hoppers, vaults, pits, and like spaces where there is limited means of entry) and is hindered or restricted from escaping during an emergency.

Construction Equipment Construction equipment refers to specialized heavy machinery that covers one industry and is specifically designed for executing construction work. Construction equipment requirements shall include a list of equipment establishing the size, quality, number of units, and unit prices. Construction equipment prices provided by the Contractor shall be the lowest price available considering the availability of equipment and the time constraints of the job. The direct equipment price shall be adjusted by all discounts and rebates that accrue to the Contractor.

All indirect cost associated with construction equipment, such as: the Contractor’s hourly composite trade wage, adjusted to allow for workforce productivity; sub-contractor cost, costs for pre-expended bin materials, shipping and handling, union agreements, crew sizes, hand tools, universal equipment (excluding construction equipment), mobilization, demobilization, payroll burdens and fringes, overtime, job (field) overhead, clerical support, supervision, inspection, fees, taxes, licenses, permits, and insurance, general and administrative (home office) overhead, profit, and all other associated markups shall not be included in the construction equipment price since the cost for these items were included in the labor hour unit price bid. Additionally, time for job preparation, safety standby personnel, and similar indirect labor elements shall not be included.

Contracting Officer (KO) That individual with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings. The term includes certain authorized representatives of the Contracting Officer acting within the limits of their authority as delegated by the Contracting Officer.

Contracting Officer’s Representative (COR)

The individual appointed by the KO responsible for monitoring the Contractor’s technical compliance and progress, relative to assigned contract(s)/orders(s), based on the contract requirements specified in the PWS and in accordance with the PAP. The COR performs a variety of contract administration duties that includes oversight of PA, documenting and rating Contractor performance, reviewing invoices, and acceptance of work. Assignment as a COR is a collateral duty typically performed by the FSCM or

SPAR.

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Attachment J-0200000-01 Definitions and Acronyms

Definition Description Contractor That entity or its representative responsible for the delivery of the services or materials specified in this contract, as designated by contract award. The term Contractor as used herein refers to both the prime Contractor and any subcontractors. The prime Contractor shall insure that subcontractors comply with the provision of this contract.

Contractor Representative That individual appointed by the Contractor, either orally or in writing, who has been assigned responsibility for executing the requirements of this contract.

Direct Material Costs The actual vendor invoice charges for materials used for performance of work under this contract. Direct material costs shall include sales tax and transportation charges when such charges are included on the invoice by the vendor, as well as any discounts allowed for prompt payment and discounts or rebates for core value or salvage value that accrue to the Contractor. When questions arise concerning the cost of direct materials, direct material costs will be based on the lowest of quotes provided by the Contractor from at least three different commercial vendors for the direct material cost. The Government retains the right to obtain additional quotes in questionable situations. The lowest price will be used.

All other cost such as sub-contractor cost, costs for pre-expended bin materials, shipping and handling, union agreements, crew sizes, hand tools, universal equipment, mobilization, demobilization, time for job preparation, safety standby personnel, payroll burdens and fringes, overtime, job (field) overhead, clerical support, supervision, inspection, fees, taxes, licenses, permits, and insurance, general and administrative (home office) overhead, profit, and all other associated markups shall not be included in the direct material price since the cost for these items are included in the UPL Hour unit price bid.

Electronic Operation And Maintenance And Support Information (eOMSI)

A set of consultant-prepared data and document files that contain detailed, as-built technical information that describes the efficient, economical and safe operation, maintenance and repair of a facility, plant, equipment or system throughout its life cycle.

Generally, it is prepared during construction and submitted upon completion of a new facility or major facility upgrade. eOMSI’s typically include asset information, staffing and budgeting information, supply support including critical spare parts, operating procedures, troubleshooting and diagnostic guides, extended warranty data, maintenance task frequencies and documentation, technical data, repair procedures and manufacturer’s product data. eOMSI data and document files are provided in electronic formats.

Equipment Tangible asset that is functionally complete for its intended purpose, durable, and non-expendable.

Facility A building or structure designed and created to serve a particular function.

Frequency Of Service Annual (A). Services performed once during each 12-month period of the contract at intervals of 335 to 395 days.

Biennial (B). Services performed once during each 24-month period of the contract at internals of 670 to 790 days.

Daily (D5). Services performed once each calendar day, Monday through Friday, including holidays unless otherwise noted.

Daily (D7). Services performed once each calendar day, seven days per week, including weekends and holidays.

Monthly (M). Services performed 12 times during each 12-month period of the contract at intervals of 28 to 31 calendar days.

Quarterly (Q). Services performed four times during each 12-month period of the contract at intervals of 80 to 100 calendar days.

Semiannual (SA). Services performed twice during each 12-month period of the contract at intervals of 160 to 200 calendar days.

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Attachment J-0200000-01 Definitions and Acronyms

Definition Description Semimonthly (SM). Services performed 24 times during each 12-month period of the contract at intervals of 14 to 16 calendar days.

Three times weekly (3W). Services performed three times a week, such as Monday, Wednesday, and Friday.

Twice weekly (2W). Services performed twice a week, such as Monday and Thursday or Tuesday and Friday.

Weekly (W). Services performed 52 times during each 12-month period of the contract at intervals of six to eight calendar days.

Government Furnished Property (GFP)

Property in the possession of, or directly acquired by, the Government and subsequently furnished to the contractor for performance of a contract. Government furnished property includes, but is not limited to, spares and property furnished for repairs, maintenance, overhaul, or modification. Government furnished property also includes contractor acquired property if the contractor acquired property is a deliverable under a cost contract when accepted by the Government for continued use under the contract.

Hazardous Material (HM) A material that because of its quality, concentration, physical, chemical or infectious nature may pose a threat to human health or the environment if released or spilled into the environment or any material designated by the Department of Transportation (DOT) or any materials that require a SDS form as posing a potential threat while being transported. Hazardous materials are listed in 49 CFR Part 172.

Hazardous Waste (HW) Any discarded solid waste (liquid, semi-solid, solid, or gaseous) that meets the definition of a hazardous waste by USEPA, state authorities, or the Navy. In accordance with RCRA, a solid waste is a listed hazardous waste if it is specifically listed, or it is a characteristic hazardous waste if it exhibits the characteristics of ignitability, corrosivity, reactivity, or toxicity.

Hazardous Waste Management Plan

In accordance with OPNAVINST 5090.1C, every Navy shore activity that generates HW shall develop and use a Hazardous Waste Management Plan or a Hazardous Waste management component in its P2 Plan and EMS. A Hazardous Waste Management Plan shall:

Identify applicable federal, state, and local regulations pertaining to the generation and management of hazardous waste.

Identify training requirements and describe procedures for obtaining training and maintaining training records.

Assign responsibilities for the generation, designation, handling, storage, treatment, disposal, and all documentation.

Describe all hazardous waste generation and management procedures.

Include or reference the hazardous waste minimization plan and goals.

Include or reference contingency plans and emergency response procedures.

The plan shall be kept up to date to include changes in hazardous waste generation and management procedures, as well as changes in applicable federal, state, and local hazardous waste regulations. The plan shall include or reference minimization procedures sufficient to achieve DOD minimization goals. Tenant activities are covered by the host CO's Hazardous Waste Management Plan.

Inspection A rigorous, detailed assessment of the condition of a facility performed to generate a fundable scope and cost estimate for prioritization and funding of maintenance and repair.

Job or Work Order An authorization for work that requires planning and estimating and has an individual line of accounting for financial and performance evaluation.

Maintenance and Repair The preservation or restoration of a piece of equipment, system, or facility to such condition that it may be effectively used for its designated purposes. Maintenance/repair may be adjustment, overhaul, reprocessing, or replacement of constituent parts or

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Attachment J-0200000-01 Definitions and Acronyms

Definition Description materials that are missing or have deteriorated by action of the elements or usage, or replacement of the entire unit or system if beyond economical repair.

Non-RCRA Regulated Waste

Waste that is not regulated as a hazardous waste under RCRA; however, is waste may be regulated by other federal, state or local regulations including but not limited to TSCA, Clean Air Act, Clean Water Act or other regulations and statues. Examples include Used Oil, Universal Waste, Oily Water, antifreeze, etc.

Non-RCRA regulated waste (while not meeting the definition of a Hazardous Waste) must be managed according to its applicable regulations and may not be discarded into the general trash.

Non-Regulated Solid Waste (Debris and Rubbish)

Waste not associated with an industrial process such as refuse and scraps resulting from preparation, cooking, dispensing, and consumption of food. Non-hazardous construction and demolition wastes such as dimension and non-dimension lumber, plywood, chipboard, and hardboard are included.

Partnering The terms “partnering” and “partnership” used herein shall mean a relationship of open communication and close cooperation that involves both Government and Contractor personnel working together for the purpose of establishing a mutually beneficial, proactive, cooperative environment within which to achieve contract objectives and resolve issues and implementing actions as required.

Performance Assessment A method used by the Government to provide some measure of control over the quality of purchased goods and services received.

Performance Assessment Representative (PAR)

The individual(s) assigned as a Technical Point of Contact (TPOC) / Subject Matter Expert (SME) to the COR to perform duties as the on-site representative who assesses Contractor performance. The PAR periodically observes Contractor performance, reviews delivered services, reviews quality management corrective actions, periodically assesses and documents Contractor performance on PAWs and the MPAS, and communicates findings as necessary with the Contractor, SPAR, and COR.

Pre-Expended Bin Materials And Supplies

The minor materials and supplies that are incidental to the job, for which the total direct cost of any one material line item shown on the material estimate is $10.00 or less.

Examples of pre-expended bin materials and supplies include, but are not limited to, solder, lead, flux, electrical connectors, electrical tape, fuses, nails, screws, bolts, nuts, washers, spacers, masking tape, sand paper, solvent, cleaners, lubricants, grease, oil, rags, mops, glue, epoxy, spackling compound, joint tape, plumbers tape and compound, clips, welding rods, and touch up paint.

Property Administrator An authorized representative of the Contracting Officer who is responsible for administering contract property requirements, terms and conditions of the contract

Property Management Program

A Government program established for the purpose of reviewing and approving the Contractor’s Property Management Plan and System through performance of a system analysis whenever government property is in the possession of the Contractor.

Quality Assurance (QA) The planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled.

Quality Control (QC) The observation techniques and activities used to fulfill requirements for quality.

R. S. Means A data collection and organization system developed by R. S. Means Company which can be used to prepare accurate, dependable construction estimates and budgets in a variety of ways. The Contractor shall use the latest edition. Material prices are based on a national average and computed labor costs are based on a 30-city national average.

An estimate prepared using this data is called a "Means estimate"; data may simply be referred to as "Means".

Regulated Waste Any hazardous, non-hazardous, industrial process waste (aka special waste), e-waste, and/or off-specification HM, which because of its physical characteristics, chemical make-up or biological nature requires either special handling procedures and permitting, N69450-23-Q-0003 Page 6 of 38 Pensacola Training Pool Services

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Attachment J-0200000-01 Definitions and Acronyms

Definition Description or poses an unusual threat to human health, equipment, property, or the environment.

Examples include (but are not limited to) liquid sludge, pastes, and/or filter cakes, chemical compounds and/or petroleum products, fine powders or highly dusty materials, spent blast media and/or grit, demolition wastes from industrial facilities, debris and/or residues from spill cleanup work, underground storage tank remediation materials, pollution control wastes, ash from fires, furnaces, boilers or incinerators, off-specification products, other materials that have the potential to be a hazardous waste.

All RW may be used or unused excess hazardous materials. Laboratory analysis may be required to verify the waste is not a RCRA-regulated hazardous waste.

Response Time The time allowed the Contractor after initial notification of a work requirement to be physically on the premises at the work site with appropriate personnel, tools, equipment, and materials, ready to perform the work required.

Unit Priced Labor (UPL) Hour

The fully burdened unit price bid by the Contractor to perform one hour of work-in-place. With the exception of direct material and construction equipment costs, the unit priced labor hour price shall include all indirect and direct costs associated with performing work, such as: the Contractor’s hourly composite trade wage, adjusted to allow for workforce productivity; sub-contractor cost, costs for pre-expended bin materials, shipping and handling, wage determinations, union agreements, crew sizes, hand tools, equipment, universal equipment (excluding construction equipment), mobilization, demobilization, payroll burdens and fringes, overtime, job (field) overhead, clerical support, supervision, inspection, fees, taxes, licenses, permits, and insurance, general and administrative (home office) overhead, profit, and all other associated markups. Any indirect cost or additional markups not allowed in the definition of direct materials shall be included in the UPL price. Additionally, time for job preparation, safety standby personnel, and similar indirect labor elements are included.

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Attachment J-0200000-01 Definitions and Acronyms

Acronym Title ACO Administrative Contracting Officer AFFF Aqueous Film Forming Foam BFR Basic Facility Requirements BW Biweekly CBMM Condition Based Maintenance Management Program CDR Contract Discrepancy Report CIA Controlled Industrial Area CIMU Component Inventory Management Unit CMMS Computerized Maintenance Management System CNSSI Committee on National Security Systems Instruction COR Contracting Officer Representative COR Condition of Readiness DBH Diameter at Breast Height DCR Direct Condition Rating DoD Department of Defense DoDI Department of Defense Instruction DoN Department of Navy DRMO Defense Reutilization Management Office EPA Environmental Protection Agency EPCRA Emergency Planning and Community Right-to-Know Act FAR Federal Acquisition Regulation FFP Firm Fixed Price FIFRA Federal Insecticide, Fungicide, and Rodenticide Act FSC Facility Support Contract FSCM Facility Support Contract Manager GIS Geospatial Information System GFE Government-furnished Equipment GFF Government-furnished Facilities GFM Government-furnished Materials HCA Head Contracting Agency ICAP Infrastructure Condition Assessment Program ICP Integrated Contingency Plan IDIQ Indefinite Delivery Indefinite Quantity iNFADS Internet Navy Facilities Asst Data Store IPM Integrated Pest Management IPMIS Integrated Pest Management Information System IPMP Integrated Pest Management Plan KO Contracting Officer LAN Local Area Network M Monthly MAP Maintenance Action Plan MDI Mission Dependency Index MEP Mechanical, Electrical and Plumbing MILCON Military Construction MPAS Monthly Performance Assessment Summary MRI Mission Readiness Index MSDS Material Safety Data Sheets NAVFAC Naval Facilities Engineering Command NIST National Institute of Standards and Technology NIST SP National Institute of Standards and Technology Special Publication NMCI Navy Marine Corps Intranet

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Attachment J-0200000-01 Definitions and Acronyms

Acronym Title NOSC Navy-On-Scene Coordinator PAP Performance Assessment Plan PAR Performance Assessment Representative PAW Performance Assessment Worksheet PEO Program Executive Officer PM Project Manager PM Planned Maintenance or Preventative Maintenance POAM Plan of Action and Milestones PRCSP Permit Required Confined Space Program PWS Performance Work Statement PWO Public Works Officer Q Quarterly QC Quality Control RSIP Regional Shore Infrastructure Plan RPIE Real Property Inventory Equipment RSL Remaining Service Life SC Security Clearances SM Semimonthly SPAR Senior Performance Assessment Representative TE Technical Exhibit VIQ Variation in Quantity WBS Work Breakdown Structure

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Attachment J-0200000-02 Directives, Instructions, and References

Reference Title EM 385-1-1 U.S. Army Corps of Engineers Safety and Health Requirements P.L. 91-596 Occupational Safety and Health Act CNRSEINST 4101.1C Region Energy Management Program OPNAVINST 5090.1 Environmental Readiness Program

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Attachment J-0200000-03 Forms

Form Description NAVFAC Contractor Significant Incident Report (CSIR) (See Form Below) Solid Waste Management Reports Form (See Form Below) Contractor Hazardous Material Inventory Log NAVFAC Form 11014/38 Inspector’s Report (See Form Below)

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Contractor Significant Incident Report (CSIR) (J-0200000-04A)

Initial Report Follow-up Report Final Report

Contractor Significant Incident Report (CSIR)

1. General Information Contracting Activity:

Accident Classification:

Injury Fatality Environment Procedural Issues

Lessons Learned

Illness Property Damage

Other_______________________________

Involving:

Confined Space Equip/Mrt Ver/Mat Handling (Heavy Construction Equip.)

Hazardous Material

Crane and Rigging Equip/Mrt Ver/Mat Handling (Material Handling)

Trenching/Excavation

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

Waterfront/Marine Operations

Demolition/Renovation Fall from Ladder Fall from Scaffold

Other___________________

Electrical Fall from Roof Fire

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

Age: Sex:

Job Title/Description:

Employed By:

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

Was the person trained to perform this activity/task?

Yes No

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

Date of the most recent formal training and topics discussed?

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

Employed By: Supervisor Name (Last, First, MI):

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

Employed By:

Supervisor Name (Last, First, MI):

Additional Witnesses: Yes

No

4. Contract Information Type of Contract:

A/E BOS CLEAN Construction Design Build FSCC

FSSC

JOC RAC Service

Other_______________________________

Contract Number & Title: Industrial Group & Industrial Type:

Prime Contractor Name/Address/Phone & Fax No:

Safety Manager (Last, First, MI):

Insurance Carrier:

Sub Contractor Name/Address/Phone & FAX No:

Safety Manager (Last, First, MI):

Insurance Carrier:

5. Accident Description Date of Accident: Time of

Accident:

Exact Location of Accident:

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

(List any additional witnesses on a separate sheet and attach.)

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Direct Cause(s) of Accident:

Indirect Cause(s) of Accident:

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

Corrective Action Beginning Date: Anticipated Completion Date:

Personal Protective Equipment:

Available and used Available and not used Not Required

Not related to Mishap Wrong PPE for job

List PPE Used:

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

Was Hazardous Material Spilled/Released?

Yes No

Please List Hazardous Material(s) Involved:

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Who provided first aid or cleanup of mishap site?

Any blood-borne pathogen exposure, other than EMTs?

Yes

No

Who?

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

Was site secured and witness statements taken immediately?

By Whom?

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

Fatality Lost Workday Case Involving Days Away From Work

Temporary Disabillity Recordable Workday Case Involving Restricted Duty

Permanent Total Disability Other Recordable Case

Recordable First Aid Case

Permanent Partial Disability Non-Recordable Case No Injury

Estimated Days Lost: Estimated Days Hospitalized:

Estimated Days Restricted Duty:

List Primary Body Part Affected:

List Other Body Part(s) Affected:

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

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

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

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7. Causal Factors (Explain answers on supplementary sheet) Design – Design of facility, workplace, or equipment was a factor? Yes No

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

Persons Physical Condition – In your opinion, the physical condition of the person was a factor? Yes No

Operation Procedures – Operating procedures were a factor? Yes No

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

Human Factors – One or more human factors, such as a person’s size or strength contributed to the accident? Yes No

Environmental Factors – Heat, cold, dust, sun, glare, etc., contributed to the accident? Yes No

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

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

Support Factors – Inappropriate tools/resources were provided to perform the task? Yes No

PPE – Improper selection, use or maintenance of PPE contributed to the accident? Yes No

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

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

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

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

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

CONTRACTOR SIGNIFICANT INCIDENT REPORT (CSIR) INSTRUCTIONS

Complete Sections Appropriate to Incident (Rev. 06/02).

NOTE: THE ATTACHED CSIR FORM IS TO BE USED BY CONTRACTORS TO RECORD THE RESULTS

OF THEIR ACCIDENT/INCIDENTS INVESTIGATIONS AND SHALL BE PROVIDED TO THE

CONTRACTING OFFICER WITHIN THE REQUIRED TIMEFRAMES.

GENERAL. Complete a separate report for each person who was injured in the accident. A report needs to be completed for all OSHA recordable accidents, property damage in excess of $2000.00 (This amount is for record purposes only. GOV is not required to enter property damage reports into FAIR database if it is less than $10,000.00.), WHE accidents, or near miss/high visibility mishaps. Please type or print legibly. Appropriate items shall be marked with an “X” in box(es), non-applicable sections shall be marked “N/A”. If additional space is needed, provide the information on a separate sheet of paper and attach to the completed form.

Mark the report:

INITIAL – If this form is being used as initial notification of a Fatality or High Visibility Mishap. The initial form is due within 4 hours of a serious accident. A form marked ‘Follow-up’ or ‘Final’ is required within 5 days.

FOLLOW-UP – If you are providing additional information on a report previously submitted.

FINAL – If you are providing a completed report and expect no changes.

SECTION 1 – GENERAL INFORMATION

CONTRACTING ACTIVITY/ROICC OFFICE - Enter the name and address of the Contracting Office administering the contract under which the mishap took place (e.g. ROICC MCBH, ROICC NORFOLK, PWC GUAM, etc.).

ACCIDENT CLASSIFICATION - INJURY/ILLNESS/FATALITY/PROPERTY DAMAGE/-PROCEDURAL

ISSUES/-ENVIRONMENTAL/LESSONS LEARNED/OTHER – Mark the appropriate block(s) if the incident resulted in any of these conditions.

INVOLVING - If the mishap involved any of the conditions listed under “Involving” mark the appropriate box(es).

Specific questions associated with each of these conditions are available from the Contracting Officer to assist you in your investigation. When these questions are used they shall be attached as part of this report.

SECTION 2 - PERSONAL INFORMATION

NAME - Enter last name, first name, middle initial of person involved.

AGE - Enter age.

SEX - Enter M for Male and F for Female.

JOB TITLE/DESCRIPTION - Enter the job title/description assigned to the injured person (e.g. carpenter, laborer, surveyor, etc.).

EMPLOYED BY - Enter employment company name of the person involved.

SUPERVISOR’S NAME & TITLE - Enter name and title of the immediate supervisor.

WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK? - For the purpose of this section “trained” means the person has been provided the necessary information (either formal and/or on-the-job (OJT) training) to competently perform the activity/task in a safe and healthful manner.

TYPE OF TRAINING - Indicate the specific type of training (classroom or on-the-job) that the injured person received before the accident happened.

DATE OF MOST RECENT FORMAL TRAINING/TOPICS DISCUSSED - Enter the month, day, and year of the last formal training completed that covered the activity/task being performed at the time of the accident. List topics that were discussed at the training identified above.

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SECTION 3 - WITNESS INFORMATION

The following applies to Witness #1 and Witness #2:

WITNESS NAME - Enter last name, first name, middle initial of the witness.

JOB DESCRIPTION/TITLE - Enter the job title/description assigned to the witness (e.g. carpenter, laborer, surveyor, etc.).

EMPLOYED BY - Enter the name of the employment company of the witness.

SUPERVISORS NAME - Enter name of immediate supervisor of the witness.

ADDITIONAL WITNESSES - Provide same information, as above, for each witnesses. Use additional pages if necessary.

SECTION 4 - CONTRACTOR INFORMATION

TYPE OF CONTRACT - Mark appropriate box. A/E means architect/engineer. If “OTHER” is marked, specify type of contract on line provided.

CONTRACT NUMBER/TITLE - Enter complete contract number and tile of prime contract (e.g. N62477-85-C- 0100, 184 Pearl City Hsg. Revitalization).

CONSTRUCTION INDUSTRIAL GROUP AND INDUSTRIAL TYPE – This is the type of construction that will be done at this project.

1. First, you must choose the Industrial Group. You have 4 choices to choose from: (NOTE! Review of the Industrial Types below and knowing what the projects scope of work is will assist you in deciding what the Industrial Group should be.)

a. Buildings

b. Heavy Industrial

c. Infrastructure

d. Light Industrial

2. Once you have chosen the Industrial Group, you now select the Industrial Type. You have multiple choices under each Group, chose the one you feel fits the project most closely because on most projects there won’t be an exact match:

a. Buildings:

(1) Communications Ctr.

(2) Dormitory/Hotel

(3) High-rise Office

(4) Hospital

(5) Housing

(6) Laboratory

(7) Low-rise Office

(8) Maintenance Facility

(9) Parking Garage

(10) Physical Fitness Ctr.

(11) Restaurant/Nightclub

(12) School

(13) Warehouse

b. Heavy Industrial:

(1) Chemical Mfg.

(2) Electrical (Generating)

(3) Environmental

(4) Metals Refining/Processing

(5) Mining

(6) Natural Gas Processing

(7) Oil Exploration/Production

(8) Oil Refining

(9) Pulp and Paper

c. Infrastructure:

(1) Airport

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(2) Electrical Distribution

(3) Flood Control

(4) Highway

(5) Marine Facilities

(6) Navigation

(7) Rail

(8) Tunneling

(9) Water/Wastewater

d. Light Industrial:

(1) Automotive Assembly/Mfg.

(2) Consumer Products Mfg.

(3) Foods

(4) Microelectronics Mfg.

(5) Office Products Mfg.

(6) Pharmaceuticals Mfg.

CONTRACTOR’S NAME/ADDRESS/PHONE NUMBER

(1) PRIME - Enter the exact name (title of firm), address, phone and fax numbers of the prime contractor.

(2) SUBCONTRACTOR - Enter the exact name, address, phone and fax numbers of any subcontractor involved in the accident.

SAFETY MANAGER’S NAME

(1) PRIME - Enter the name of the prime contractor safety manager.

(2) SUBCONTRACTOR - Enter the name of the subcontractors safety manager.

INSURANCE CARRIER

(1) PRIME - Enter the exact name/title of the prime’s insurance company. Policy number not required.

(2) SUBCONTRACTOR - Enter the exact name of the subcontractor’s insurance company. Policy number not required.

SECTION 5 - ACCIDENT DESCRIPTION

DATE OF ACCIDENT - Enter the month, day, and year of accident.

TIME OF ACCIDENT - Enter the local time of accident in military time. Example: 14:30 hrs. (not 2:30 p.m.).

EXACT LOCATION OF ACCIDENT - Enter facts needed to locate the accident scene (installation/project name, building/room number, street, direction and distance from closest landmark, etc.).

DESCRIBE THE ACCIDENT IN DETAIL. Fully describe the accident in the space provided. If property damage involved, give estimated dollar amount of damage and/or repair costs involved. If additional space is needed continue on a separate sheet and attach to this report. Give the sequence of events that describe what happened leading up to and including the accident. Fully identify personnel and equipment involved and their role(s) in the accident. Ensure that relationships between personnel and equipment are clearly specified. Ensure questions below regarding direct cause(s), indirect cause(s), and actions taken are answered. NOTE! Review questions in Section 7 below before completing.

DIRECT CAUSE(S) - The direct cause is that single factor which most directly leads to the accident. See examples below.

INDIRECT CAUSE(S) - Indirect cause are those factors, which contributed to, but did not directly initiate the occurrence of the accident.

Examples for Direct and Indirect Cause:

1. Employee was dismantling scaffold and fell 12 feet from unguarded opening.

Direct cause: Failure to provide fall protection at elevation Indirect causes: Failure to enforce safety requirements: improper training/motivation of employee (possibility that employee was not knowledgeable of fall protection requirements or was lax in his attitude toward safety); failure to ensure provision of positive fall protection whenever elevated; failure to address fall protection during scaffold dismantling in phase hazard analysis.

2. Private citizen had stopped his vehicle at intersection for red light when vehicle was struck in rear by contractor vehicle. (note contractor vehicles was in proper safe working condition.)

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Direct cause: Failure of contractor driver to maintain control of and stop contractor vehicle within safe distance.

Indirect cause: Failure of employee to pay attention to driving (defensive driving).

ACTION(S) TAKEN TO PREVENT RE-OCCURRENCE OR PROVIDE ON-GOING CORRECTIVE ACTIONS.

Fully describe all the actions taken, anticipated, and recommended to eliminate the cause(s) and prevent reoccurrence of similar accidents/illnesses. Continue on back or additional sheets of paper if necessary to fully explain and attach to the complete report form.

CORRECTIVE ACTION DATES -

(1) Beginning - Enter the date when the corrective action(s) identified above will begin.

(2) Anticipated Completion - Enter the date when the corrective action(s) identified above will be completed.

PERSONAL PROTECTIVE EQUIPMENT (PPE) - Mark appropriate box(es) and list PPE which was being used by the injured person at the time of the accident (e.g. protective clothing, shoes, glasses, goggles, respirator, safety belt, harness, etc.)

TYPE OF CONTRACTOR EQUIPMENT - Enter the Serial Number, Model Number and specific type of equipment involved in the mishap (e.g. dump truck (off highway), crane (rubber tire), pump truck (concrete), etc.).

WAS HAZARDOUS MATERIAL SPILLED/RELEASED? - Mark appropriate block and list name(s) of any reportable quantities of hazardous materials spilled/released during the mishap.

WHO PROVIDED FIRST AID OR CLEAN-UP OF MISHAP SITE? - List name(s) of individual(s) and employer, if known.

ANY BLOOD-BORNE PATHOGEN EXPOSURE, OTHER THAN EMT? - Mark appropriate block and list name(s) of individual(s) and employer, if known.

LIST OSHA AND/OR EM 385-1-1 STANDARDS THAT WERE VIOLATED. – Self-explanatory.

WAS SITE SECURED AND WITNESS STATEMENT TAKEN IMMEDIATELY? - Mark appropriate block and list by whom.

SECTION 6 - INJURY/ILLNESS/FATALITY INFORMATION

SERVERITY OF INJURY/ILLNESS – Mark appropriate box.

ESTIMATED DAYS LOST - Enter the estimated number of workdays the person will lose from work. Update when final data is known.

ESTIMATED DAYS HOSPITALIZED - Enter the estimated number of workdays the person will be hospitalized.

Update when final data is known.

ESTIMATED DAYS RESTRICTED DUTY - Enter the estimated number of workdays the person, as a result of the accident, will not be able to perform all of their regular duties. Update when final data is known.

BODY PART(S) AFFECTED - Enter the most appropriate primary and when applicable, secondary, etc. body part(s) affected (e.g. arm: wrist: abdomen: single eye; jaw: both elbows: second finger: great toe: collar bone:

kidney, etc.).

NATURE OF INJURY/ILLNESS FOR PRIMARY BODY PART - Enter the most appropriate nature of injury/illness (e.g. amputation, back strain, dislocation, laceration, strain, asbestosis, food poisoning, heart conditions, etc.).

TYPE AND SOURCE OF INJURY/ILLNESS - Type and Source Codes are used to describe what caused the incident.

(1) TYPE Code stands for an “Action” (Example: Worker, installing conduit, lost his balance and fell five feet from a ladder. Type Code: Fell different levels”.) Select the most appropriate Type of injury from the list below:

TYPE OF INJURY/ILLNESS

STRUCK

BY/AGAINST

CONTACTED

CONTACTED WITH (INJURED PERSON

MOVING)

CONTACTED BY (OBJECT WAS MOVING)

FELL, SLIPPED, TRIPPED

SAME LEVEL/DIFFERENT LEVEL/NO

FALL

EXERTED

LIFTED, STRAINED BY (SINGLE ACTION)

STRESSED BY (REPEATED ACTION)

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CAUGHT

ON/IN/BETWEEN

EXPOSED

INHALED/INGESTED/ABSORBED/EXPOSED

TO

PUNCTURED, LACERATED

PUNCTURED BY/CUT BY/STUNG

BY/BITTEN BY

TRAVELING IN

(2) SOURCE Code stands for an “object or substance.” (Example: Worker, installing conduit, lost his balance and fell five feet from a ladder. Source Code: “Ladder”.) Select the most appropriate Source of injury from the list below:

SOURCE OF INJURY/ILLNESS

Building or Working Area Walking/Working Area Stairs/Steps

Ladder Furniture Boiler/Pressure Vessel Equipment Layout Windows/Doors Electricity

Dust, Vapor, Etc.

Dust (Silica, Coat, Etc.)

Fibers

Asbestos Gases Carbon Monoxide Mist, Steam, Vapor, Fume Welding Fumes

Particles (Unidentified) Environment Condition Temperature Extreme (Indoor) Weather (Ice, Rain, Heat, etc.)

Fire, Flame, Smoke (Not Tobacco) Noise Radiation Light Ventilation Tobacco Smoke Stress (Emotional) Confined Space

Chemical, Plastic, etc.

Dry Chemical - Corrosive

Dry Chemical - Toxic Dry Chemical - Explosive Dry Chemical - Flammable Liquid Chemical - Corrosive Liquid Chemical - Toxic Liquid Chemical - Explosive Liquid Chemical - Flammable Plastic Water

Medicine Machine or Tool Hand Tool (Powered: Saw, Grinder, etc.)

Hand Tool (Non Powered) Mechanical Power Transmission Apparatus Guard, Shield (Fixed, Moveable, Interlock) Video Display Terminal Pump, Compressor, Air Pressure Tool Heating Equipment Welding Equipment

Inanimate Object Box, Barrel, etc.

Paper Metal Item, Mineral Needle Glass Scrap, Trash, Wood Food Clothing, Apparel, Shoes

Machine or Tool Hand Tool (Powered: Saw, Grinder, etc.)

Hand Tool (Non Powered) Mechanical Power Transmission Apparatus Guard, Shield (Fixed, Moveable, Interlock) Video Display Terminal Pump, Compressor, Air Pressure Tool Heating Equipment Welding Equipment

Inanimate Object Box, Barrel, etc.

Paper Metal Item, Mineral Needle Glass Scrap, Trash, Wood Food

Clothing, Apparel, Shoes

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Vehicle As Driver of Privately Owned, Rental Vehicle.

As Passenger of Privately Owned, Rental Vehicle.

Driver of Government Vehicle Passenger of Government Vehicle Common Carrier (Airline, Bus, etc.)

Aircraft (Not Commercial) Boat, Ship, Barge

Animate Object Dog Other Animal Plant Insect Human (Violence)

Human (Communicable Disease) Bacteria, Virus (Not Human Contact)

Material Handling Equipment Earthmover (Tractor, Backhoe, etc.)

Conveyor (For Material and Equipment) Elevator, Escalator, Personnel Hoist Hoist, Sling Chain, Jack Crane Forklift Hand truck , Dolly

Personal Protective Equipment Protective Clothing, Shoes, Glasses, Goggles Respirator, Mask

Diving Equipment Safety Belt, Harness Parachute

SECTION 7 - CAUSAL FACTORS

Review thoroughly. Answer each question by marking the appropriate block. NOTE! If any answer is yes, explain in section 5 above.

(1) DESIGN - Did inadequacies associated with the building or work site play a role? Would an improved design or layout of the equipment or facilities reduce the likelihood of similar accidents? Were the tools or other equipment designed and intended for the task at hand?

(2) INSPECTION/MAINTENANCE - Did inadequately or improperly maintained equipment, tools, workplace, etc., create or worsen any hazards that contributed to the accident? Would better equipment, facility, work site or work activity inspections have helped avoid the accident?

(3) PERSONS PHYSICAL CONDITION - Do you feel that the accident would probably not have occurred if the employee was in “good” physical condition? If the person involved in the accident had been in better physical condition, would the accident have been less severe or avoided altogether? Was overexertion a factor?

(4) OPERATION PROCEDURES - Did lack of or inadequacy within established operating procedures contribute to the accident? Did any aspect of the procedures introduce any hazard to, or increase the risk associated with the work process? Would establishment or improvement of operating procedures reduce the likelihood of similar accidents?

(5) JOB PRACTICES - Were any of the provision of the Safety and Health Requirements Manual (EM 385-1-1) violated? Was the task being accomplished in a manner which was not in compliance with an established job hazard analysis or activity hazard analysis? Did any established job practice (including EM 385-1-1) fail to adequately address the task or work process? Would better job practices improve the safety of the task?

(6) HUMAN FACTORS - Was the person under undue stress (either internal or external to the job)? Did the task tend toward overloading the capabilities of the person: i.e., did the job require tracking and reacting to many external inputs such as displays, alarms, or signals? Did the arrangement of the workplace tend to interfere with efficient task performance? Did the task require reach strengths, endurance, agility, etc., at or beyond the capabilities of the employee? Was the work environment ill-adapted to the person? Did the person need more training, experience, or practice in doing the task? Was the person inadequately rested to perform safely?

(7) ENVIRONMENTAL FACTORS - Did any factors such as moisture, humidity, rain, snow, sleet, hail, ice, fog, cold, heat, sun temperature changes, wind, tides, floods, currents, terrain; dust, mud, glare, pressure changes, lighting, etc., play a part in the accident?

(8) CHEMICAL AND PHYSICAL AGENT FACTORS - Did exposure to chemical agents (either single shift exposure or long-term exposure such as dusts, fibers, (asbestos, etc.), silica, gases (carbon, monoxide, chlorine, etc.), mists, steam, vapors, fumes, smoke, other particulates, liquid or dry chemicals that are corrosive, toxic, explosive or flammable, by-products of combustion or physical agents such as noise, ionizing radiation, non-ionizing radiation (UV radiation created during welding, etc.) contribute to the accident/incident?

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(9) OFFICE FACTORS - Did the fact that the accident occurred in an office setting or to an office worker have a bearing on its cause? For example, office workers tend to have less experience and training in performing tasks such as lifting office furniture. Did physical hazards within the office environment contribute to the hazard?

(10) SUPPORT FACTORS - Was the person using an improper tool for the job? Was inadequate time available or utilized to safely accomplish the task? Were less than adequate personnel resources (in terms of employee skills, number of workers, and adequate supervision) available to get the job done properly? Was funding available, utilized and adequate to provide proper tools, equipment, personnel, site preparation, etc.

(11) PERSONAL PROTECTIVE EQUIPMENT - Did the person fail to use appropriate personal protective equipment (gloves, eye protection, hard-toed shoes, respirator, etc.) for the task or environment? Did protective equipment provided or worn fail to provide adequate protection from the hazard(s)? Did lack of or inadequate maintenance of protective gear contribute to the accident?

(12) DRUGS/ALCOHOL - Is there any reason to believe the person’s mental or physical capabilities, judgment, etc., were impaired or altered by the use of drugs or alcohol? Consider the effects of prescription medicine and over the counter medications as well as illicit drug use. Consider the effect of drug or alcohol induced “hangovers”.

(13) JOB/ACTIVITY HAZARD ANALYSIS - Was a written Job/Activity Analysis completed for the task being performed at the time of the accident? If one was made, did it address the hazard adequately or does it need to be updated? If none made, will one be made? These may also need to be addressed in the Corrective Actions Taken section. Mark the appropriate box. If one was made, attach a copy of the analysis to the report.

(14) MANAGEMENT - Did the lack of supervisor or management support play a part in the mishap?

Mark the appropriate box.

SECTION - 8 OSHA INFORMATION - Complete this section if applicable

SECTION 9 - REPORT PREPARER

Providing a completed CSIR to the Contracting Officer is the PRIME CONTRACTOR’S RESPONSIBILITY.

Enter the name, date of report, title, employer, phone number and signature of person completing the accident report and provide it to the Contracting Officer, or his representative, responsible for oversight of that contractor activity. NOTE! If prepared by other than the Prime Contractor, a person employed by the Prime Contractor must sign that they have reviewed and concur with the report and its findings (e.g. company owner, project supervisor/foreman, Safety Officer, etc.).

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Solid Waste Management Report

Solid Waste Recycled

Description Amount

(lbs./tons) Cost Revenue Glass Metal (aluminum, circuit boards, steel) Paper & Paper Board Plastic Food (cooking grease & oil, discarded food) Wood (packaging, pallets, plywood) Yard/Green Waste (mulch, trees, trimmings) Concrete Asphalt

Select Waste

Description Amount

(lbs./tons) Cost Revenue Construction and Demolition Debris Used Oil Ethylene Glycol Antifreeze Lead-Acid Batteries

Other Waste

Description Amount

(lbs./tons) Cost Revenue Sewage Sludge (land applied) Sewage Sludge (disposed) Oil Water Separator Liquids OWWO Oil OWWO Sludge Lift Station Grease Other Waste (SPECIFY)

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Attachment J-0200000-04 Contractor Hazardous Material Inventory Log

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Attachment J-0200000-05…