Attachment_1_SAFETY_PROCEDURES_5-13-09.doc
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Attachment 1 Safety Procedures 5-13-09 GUIDE FOR PREPARATION OF ACCIDENT PREVENTION PLANS
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SAFETY PROCEDURES (5/13/09)
ACCIDENT PREVENTION PROVISIONS FOR CONTRACTORS
GUIDE FOR PREPARATION OF ACCIDENT PREVENTION PLANS
1. Instruction and Training. Set forth initial indoctrination and continuing training, such as "tool boxll safety meetings. Such meetings to be recorded on reverse side of AMD Safety Form-03.
2. Accident Reporting.
a. The Plan must state that all lost time injuries and property damage accidents (excluding on-the-road vehicle accidents) in which the property damage exceeds $2,000 will be reported to the COTR within 8 hours of the accident/incident, using the AMD Safety Form-05 “Contractor Accident Report”.
b. The Plan must also state that in the event of an employee being sent to the doctor for treatment, a release will be obtained from the doctor on the date of treatment stating either: (1) employee not fit for duty; (2) employee fit for light duty; or (3) employee fit for duty. Copy of this release must accompany accident report.
c. The following reporting procedures apply to all Contractors and their employees performing at NIST Gaithersburg or NIST Boulder.
(1) In the event of an accident which results in a lost work day or in property damage, an AMD Safety Form-05 will be completed and submitted within five (5) workdays.
(2) The following signature chain is to be used on the AMD Safety Form-05 on Construction accidents. After each signature the name must be typed or printed legibly.
(a) Superintendent
(b) COSR
(c) COTR
(3) All AMD Safety Forms will be provided at the Pre-Construction Conference.
3. Sanitation.
a. The Plan must set forth where drinking water will be obtained, type of dispenser, and provisions for receptacle for disposable cups.
b. The Plan must include what type of toilets, how many will be provided and how will they be kept clean.
4. Medical Facilities.
a. The Plan must set forth name, address, and telephone number for doctor, hospital, and ambulance service to be used. These emergency numbers must be posted on the bulletin board.
b. First aid requirements for the Plan should show type and number of first aid kits and set forth requirement that at least two employees on each shift and at each differing location, will be qualified to administer First Aid and CPR (Cardiopulmonary Resuscitation). The minimum qualification for these employees is a current certification from American Red Cross, United States Bureau of Mines, or equivalent training that can be verified by documentary evidence.
5. Emergency Plans. The Plan must set forth provisions for preparation of action in the event of severe weather, i.e., hurricane, blizzard, high seas, etc.
6. Personal Protective Equipment.
a. The Plan must set forth requirement for all employees to wear a "T-shirt" as minimum on upper part of body. Shorts are not permitted. No tennis shoes or sandals are permitted.
b. Hard hats must meet requirements for Type A or Type B as defined by American National Standards Institute. (No metal hard hats or bump caps.) How you plan to mark HARD HAT AREAS.
c. Provisions for other protective equipment.
7. Housekeeping.
a. Daily job site cleanup required.
b. Nails must be removed from scrap lumber.
c. All stairways, passageways, gangways, and access ways must be kept free of material, supplies, and obstructions at all times.
8. Fire Prevention. The Plan must cover use of fire extinguishers, cleanup, heating devices, and flammable and combustible liquids (including safety cans and precautions to be taken with bulk gasoline storage).
9. Ropes, Slings, and Chains. The Plan must cover condition of same and usage; when slings and chains will be replaced, etc.
11. Floor and Wall Openings. If your contract covers erection, maintenance, or alteration of buildings, then your Plan must set forth precautions you will take to guard floor, wall or roof openings.
12. Noise Control.
13. Hot Substances. Set forth measures to be used with tar kettles (temperature gauges, etc.).
14. Welding, Cutting and Grounding of Machinery. Cover precautions to be used in these operations (fire extinguishers, shields, grounding of electric welders, insulation of welding leads, etc.).
15. Electrical.
a. All temporary electrical work must be done in accordance 20 CFR 1926, Subpart K (special emphasis on weekly inspection, use of NEMA configuration on all plugs and connections, and type extension cords).
b. Portable generators must be grounded as required by the National Electric Code (NEC).
c. The use of GFCls is required in addition to appropriate grounding.
16. Hand Tools and Power Tools. Cover condition of same and use safety lashing on pneumatic lines; and authorization for use of explosive actuated tools.
17. Compressed Gas Cylinders. The Plan must set forth the precautions you will utilize to prevent accidents from these cylinders.
a. Separation of different gases.
b. Protection of cylinders.
c. Utilization of valve caps.
d. Securing cylinders in upright position.
18. Ramps, Runways, Platforms, and Scaffolds. Include in this section of your Plan those items in that apply to work under your contract. Include requirements of 29 CFR 1926, Subpart L. This will include, but not be limited to:
a. Safety factors of all such devices.
b. Use of ladders as working platforms.
c. Method of erecting, supporting, and using scaffolding.
d. Means of access to working surfaces--climbing of end pieces of scaffolds is prohibited.
e. Roofing devices and practices
19. Excavations. If there will be excavation (footings, trenches, etc.) as part of your contract, then set forth procedures you will follow in accordance with 29 CFR 1926, Subpart P.
20. Clearing. The Plan must set forth actions you will take to assure safe operation of chain saws and other clearing devices.
21. Material Handling, Storage and Disposal. The Plan should address the location of storage facilities, compatibility of materials, and disposal of materials.
22. Hazardous Materials. The Plan should state method of providing workers with access to Material Safety Data Sheets, method of disposal, and compliance with federal, state, and local laws and regulations.
25. General. It is probable that all of the above areas will not apply to your contract. No attempt has been made to cover all eventualities. This guide is intended only to serve as just that -- a guide to assist you in preparing an Accident Prevention Plan that will be acceptable for work to be performed under your contract.
GUIDE FOR PREPARATION OF AN ACTIVITY HAZARD ANALYSIS (AHA)
1. Purpose. Provides guidance in preparing an Activity Hazard Analysis (AHA).
2. Applicability. This applies to all contracts for NIST Gaithersburg and NIST Boulder.
3. Policy. An AHA for each major phase of work is required. This analysis, utilized correctly, will have favorable effects on your safety record. This section provides guidance for preparing an AHA through a step-by-step procedure giving an example, explanations, and definitions. By showing this procedure, we hope to increase your understanding of how and why the analysis is used.
4. Overview.
a. An AHA is a procedure used to review job methods and identify hazards. These hazards may have been overlooked from the start or they may have developed after production work has started. Once the hazards are known, the best solution or control can then be developed.
b. The person best suited to develop the analysis is the Contractor’s Superintendent. The Superintendent is best suited to develop the AHA because he is likely to have 5-10 years of experience doing the work to be analyzed. He has made the mistakes, seen the hazards, and probably has the best suggestions on how to make the job safer and most beneficial. In addition, he is best qualified to break the job down into successive steps.
c. Once the analysis' rough draft is completed, we recommend that it be reviewed by a safety person – someone within the organization that has safety responsibilities within their job duties. The safety person should review the analysis on a technical level, check to see that no hazards were overlooked, and examine the control measures to see that the most effective measures are being used.
5. Procedures.
A. Step 1 - Selecting An Activity To Analyze.
(1) An activity is a sequence of separate steps that together accomplish a work goal. Some activities can be too broadly defined in general terms of what is accomplished. Building a new dorm,are examples. Such broadly defined activities are not suitable for an activity hazard analysis. Similarly, an activity can be too narrowly defined in terms of a single action. Pulling a switch, tightening a screw, pushing a button are examples. Such narrowly defined activities are also not suitable for an AHA.
(2) Activities suitable for a hazard analysis are those assigned generally to a line supervisor and related to a particular phase of work. Erecting block walls, placing a roof and painting are good subjects for an activity hazard analysis.
(3) Once an activity or major phase has been selected we recommend completing the analysis using the format in Appendix D, “Sample Activity Hazard Analysis (AHA)”. Note that the activity chosen for the example is Interior Demolition of the US Army Reserve Center.
B. Step 2 - Break Activity Down Into Successive Steps
(1) Now the activity is broken down into its principal steps. Usually you, the line supervisor or foreman, will rely on past experience with the type of work being analyzed. You know your work goal (end point), the beginning point, and what you have to do to accomplish the work goal (steps). You should be able to visualize a logical procession step by step.
(2) Record the steps in their natural order of occurrence. Describe what is done, but not the details of how it is done. Usually three or four words are sufficient. Number the steps consecutively.
(3) In the example, our progression of principal steps include the following: remove furniture from office; remove plumbing, electrical and HVAC duct work from partitions; demolish interior; and clean up. This shows a logical progression from point A (an old deteriorated interior) to point B (the state of final preparation for the next activity - Creating A New Interior).
C. Step 3 - Identify Hazards and Potential Accidents
(1) Once the principal steps have been identified and logged on the form, identify the potential hazards encountered in each of the principal steps listed. Once again past experience will be relied upon heavily. Also, talking with workers about past accidents or near misses will be of help to you. Checking with first aid logs or accident investigations will also help. At this point, evaluate hazards presented by other activities working adjacent to the activity being analyzed.
(2)The following is a list of questions that will also help you identify most of the hazards:
(a) Is there danger of striking against, being struck by or otherwise making injurious contact with the object?
(b) Can the employee be caught on, in, or between the object?
(c) Can the employee slip or trip? Can the employee fall on the same level or to another level?
(d) Can the employee strain themselves by pushing, pulling or lifting?
(e) Is there a possibility of electrical, health, or fire hazards associated with that principal step?
(3)It is estimated that with these questions you should be able to uncover 90% of the potential hazards. What about the other 10%? The other 10% is what makes the activity hazard analysis so unique. This is why the so called "generic analysis" is so incomplete. Factors which are unique to an activity (elevation, terrain, weather, etc.) may add to or change the potential hazards. All this must be taken into consideration when doing the analysis.
(4) In the example, we have listed most of the hazards associated with the principal steps. These are very general due to the lack of specific project information. The purpose of this is to keep the analysis simple and easy to follow. Had the Contractor’s Superintendent prepared the analysis in accordance with all the specific information available, it would be more complete and extensive.
D. Step 4 - Develop a Control for Each Hazard Identified.
(1)This is where you come up with the methods of controlling the hazards identified in Step 3 of this procedure. There may be several solutions to controlling the hazard; we want the best solution (that which is most beneficial). Ask yourself "What are the benefits to this solution?" Sometimes the solution will solve that particular problem but create a new hazard for that step or another step. Once again it is useful to ask workers for suggestions.
(2)The following are suggestions to help you come up with ideas for the best solution to your particular hazard:
(a)Change the physical conditions that create the hazard. "What change in physical condition will eliminate the hazard or prevent the accident?" A good example of this would be changing the surface in a work area to a non-slip type surface. Supplying ear muffs to a worker who must travel through an area in which noise levels exceed the standard would be another.
(b)Change the procedures of the Steps in the AHA. "What should the employee do or not do to eliminate the hazard or prevent this potential accident?" For example, "Is there another way for the employee to reach the work station other than going through the noisy area?" If there is, will it be more or less hazardous for the employee? You should consider work saving tools or equipment. For example, say an employee must lift and carry a heavy object to a workbench. All you need to do is supply the worker with a workbench that has casters. Also, if two workers were to lift the object, you would reduce the risk of back injury.
(c)Reduce the frequency that a task must be performed. Every task has some potential for an accident to occur. Therefore, when you increase the times that the task is performed, you increase the probability of an accident occurring.
(d)Training. If none of the previous suggestions are applicable, then the answer may be training the employees to do a task safely. Quite often we hear of accidents caused by lack of knowledge of proper safe procedures. This could mean a simple instruction from the Contractor’s Superintendent or could involve specialized training from an outside source. The latter is recommended for irregular work which may be unique.
(3)We have found that special attention should be given to newer employees (1 to 1 1/2 years). These employees have proven to be among the most likely to have an accident. This is why it is good practice for employers to give new employees good initial safety training.
(4)Once you have decided on a control for the hazard, you must put it into a positive statement; i.e. Dust respirators will be supplied to the workmen. Electricity will be locked out by a mechanical device. In other words you will be committing yourself to perform the action you chose to control the hazard.
(5)If you now turn to Appendix D, you will find a copy of our sample completed analysis. As an exercise, go back through Step 1 through Step 4 of the analysis. See if you can come up with anything that we left out.
6. Update as Needed. It should be noted that the completed analysis is not set in stone. We all know that field changes take place every day. With these changes a new hazard may arise. Also, a delay in a different activity could have you working next to that operation. This could add numerous hazards to your job. For an Activity Hazard Analysis to be most effective it must be updated as the activity progresses.
7. Benefits.
a. A properly completed activity hazard analysis will reap many rewards. How much does your organization spend for worker’s compensation insurance premiums? What you pay in premiums largely depends on your past accident history. If you can reduce your number of accidents using the activity hazard analysis process, then you can expect to see a reduction in your worker's compensation premiums. With lower premiums follows a lower quotation or bid. This means that your organization could be more competitive for various jobs.
b. Accidents cost money. For every accident there are obvious costs (doctor, hospitals, etc.) as well as hidden costs (training a new employee, drop in morale, wages lost in reacting to the accident, etc.). By reducing the accidents, you can save money, thereby increasing your profit margins on each job.
c. Safety training benefits your organization. Establishing safety contacts between line supervisor and worker (one-on-one) promotes good safety awareness and increases morale. This is very important for new employees.
d. Training on the proper methods of performing certain tasks will in most cases increase productivity. An increase in productivity should turn into an increase in profits.
SAMPLE ACTIVITY HAZARD ANALYSIS (AHA)
ACTIVITY: ______________
ANALYZED BY/DATE:
NOTE: For additional guidance see instructions
| PRINCIPAL STEPS |
| POTENTIAL SAFETY/ HEALTH |
HAZARDS
RECOMMENDED CONTROLS
| Identify the principal steps involved and the sequence of work activities |
| Analyze each principal step for potential hazards |
| Develop specific controls for potential hazard |
| EQUIPMENT TO BE USED |
| INSPECTION REQUIREMENTS |
| TRAINING REQUIREMENTS |
| List equipment/machinery to be used in the work activity |
| List inspection requirements for the work activity |
| List training requirements, including hazard communication |
SAMPLE ACTIVITY HAZARD ANALYSIS (AHA)
ACTIVITY: Interior Demolition, Army Reserve Center, Your City, FI ANALYZED BY: John Doe. Project Foreman 8/30/2004
NOTE: For additional guidance
| PRINCIPAL STEPS |
| POTENTIAL SAFETY/HEALTH |
HAZARDS
RECOMMENDED CONTROLS
1. Remove furniture from work area.
2. Disconnect plumbing, electrical, and HVAC duct work from interior
3. Demolish Interior
4. Clean Up
| EQUIPMENT TO BE USED |
| INSPECTION REQUIREMENTS |
| TRAINING REQUIREMENTS |
ANALYZED BY/DATE: John Doe. Project Foreman 8/30/2004
NOTE: For additional guidance
| PRINCIPAL STEPS |
| POTENTIAL SAFETY/HEALTH HAZARDS |
| RECOMMENDED CONTROLS |
| 1. Remove furniture from work area |
| 1. Back injury |
2. Foot injury
3. Hand injury
2. Disconnect plumbing, electrical, and HVAC ductwork from interior
1. Electrocution or shock from wires
2. Workers or tools falling from elevated work area
3. Asbestos from hot water pipe insulation
4. Slips, trips, or falls
5. Noise
6. Dust
7. Materials falling on workers
8. Fire/explosion
9. Cuts from pipes or ducts
| 3. Demolish Interior |
| 1. Dust |
2. Eye injury
3. Debris falling on workers
4. Workers, debris, or tools falling from elevated work area
5. Cuts/puncture wounds
6. Fire/explosion
7. Noise
| 4. Clean Up |
| 1. Dust |
2. Fire/explosion
ANALYZED BY/DATE: John Doe. Project Foreman 8/30/2004
NOTE: For additional guidance
| PRINCIPAL STEPS |
| POTENTIAL SAFETY/HEALTH HAZARDS |
| RECOMMENDED CONTROLS |
| 1. Remove furniture from work area |
| 1. Back injury |
| 1. Use furniture dolly for large or bulky furniture. Two workers required for placing large or bulky furniture onto dolly and moving large furniture. |
2. Workers to use proper lifting techniques to prevent back injury
| 2. Foot injury |
| 1. Wear steel toed safety boots. |
| 3. Hand injury |
| 1. Wear leather gloves to prevent cuts and abrasions. |
| 2. Disconnect plumbing, electrical, and HVAC duct work from interior |
| 1. Electrocution or shock from wires |
| 1. Have licensed electrician ensure electrical system is locked/tagged out. |
| 2. Workers or tools falling from elevated work area |
| 1. Provide scaffold with standard railing with toe boards. |
| 3. Asbestos from hot water pipe insulation |
| 1. Have asbestos removed by |
qualified licensed source prior to disconnecting hot water pipe.
| 4. Slips, trips, or falls |
| 1. Ensure spills from removal of plumbing have been cleaned up to prevent slips and falls. Keep work areas such as aisles, stairs, and exits clear of debris. |
| 5. Noise |
| 1. Ensure earplugs are worn in designated areas. |
| 6. Dust |
| 1. Wear dust respirators and safety glasses with side-shields or dust goggles. |
2. Provide fans for ventilation
ACTIVITY: Interior Demolition. Army Reserve Center. Your City. FI ANALYZED BY/DATE: John Doe. Project Foreman 8/30/2004 NOTE: For additional guidance
PRINCIPAL STEPS
RECOMMENDED CONTROLS
7. Material falling on workers
8. Fire/explosion
1. Wear hard hats at all times while in the construction zone.
1. Prohibit smoking in work area.
2. Ensure an adequate number of fire extinguishers of the correct size and type are provided and that workers are trained in using extinguishers.
| 9. Cuts from pipes and ducts |
| 1. Wear leather gloves to prevent |
cuts and abrasions. Tape sharp edges if possible.
| 3. Demolish interior |
| 1. Dust |
| 1. Wear dust respirators and safety glasses with side-shields or dust goggles. |
| 2. Eye injury |
| 1. Wear safety glasses with side· |
shields or dust goggles. For more severe conditions, wear face shield over safety glasses or dust goggles.
| 3. Debris falling on workers |
| 1. Rope off areas and post signs |
when demolition begins.
2. Post watch person during demolition.
3. Workers shall wear hard hats at all times while in the construction zone.
4. Workers or tools falling from elevated work area.
1. Provide scaffold with standard railing and toe boards.
2. Supply 15 gauge U.S. standard wire 1/4" mesh between toe board and guardrail around entire perimeter scaffold.
ANALYZED BY/DATE: John Doe. Project Foreman 8/30/2004
NOTE: For additional guidance
| PRINCIPAL STEPS |
| POTENTIAL SAFETY/HEALTH HAZARDS |
| RECOMMENDED CONTROLS |
| 5. Cuts/puncture wounds |
| 1. Remove nails from scrap lumber. |
2. Wear steel-toed safety boots.
3. Wear leather gloves.
| 6. Fire/explosion |
| 1. Remove all scrap lumber after every shift. |
2. Vacuum dust from work area after every shift.
3. Prohibit smoking in work area.
4. Ensure an adequate number of fire extinguishers of the correct size and type are provided and that workers are trained in using extinguishers.
| 7. Noise |
| 1. Ensure earplugs are worn in |
designated areas.
| 4. Clean up |
| 1. Dust |
| 1. Wear dust respirators and safety glasses with side-shields or dust goggles. For more severe conditions, wear face shield over safety glasses or dust goggles. |
2. Provide fans for ventilation.
| 2. Fire/explosion |
| 1. Prohibit smoking in work area. |
2. Vacuum dust from work area after every shift.
3. Ensure an adequate number of fire extinguishers of the correct size and type are provided and that workers are trained in using extinguishers.
WEEKLY CONSTRUCTION SAFETY MEETING
Each 30 minutes meeting should include:
1. Contracting Officer/Specialist
2. Contracting Officer’s Technical Representative (COTR)
3. Contracting Officer’s Safety Representative (COSR)
4. Contractor’s Safety Representative
5. Contractor’s Superintendent
6. Guest
AGENDA
I. INTRODUCTION
II. OLD BUSINESS
III. NEW BUSINESS (such as employee safety concerns, PPE, or coordination with other crafts) A. Topics
B. Events/Occurrences
C. Injuries/Illnesses
D. Results of Safety Inspections/Walkthroughs
E. Construction Communiqués/Lessons Learned and Issues
IV. CONTRACTOR’S SAFETY REPRESENTATIVE
V. OTHER
| Superintendent: |
| Date: |
| COSR: |
| Date: |
| COTR: |
| Date: |
AMD Safety Form-01 (Jan. 09)
CONTRACTOR’S SAFETY MEETING
| Contract No.: |
| Sign-In Roster |
| Date: |
Topics
1. 6._____________________________
2. ______ 7._____________________________
3. 8._____________________________
4. 9._____________________________
5. 10._____________________________
| Name (Signature) |
| Badge No. |
| Comments/Safety Concerns/Training Requests |
Superintendent Name (Print):
Superintendent Signature:
| COSR Name (Print): |
| COSR Signature: |
| COTR Name (Print): |
| COTR Signature: |
AMD Safety Form-02 (Jan. 09)
SAFETY PLANNING SIGN-OFF
I have read the attached Activity Hazard Analysis attachments and understand the hazards associated with this job.
Pre-job meeting – general
Other (specify) ________
Energized work permit pre-job
Confined space pre-entry meeting
Fall protection work plan
Asbestos work plan
| Contract Number: |
| Job Location: |
| Date |
| Contractor Name (Print) |
| Signature |
Superintendent Name (Print):
Signature
COSR Name (Print):
Signature
COTR Name (Print):
Signature
AMD Safety Form-03 (Jan. 09)
CONTRACT SAFETY ANALYSIS
(Cover Page of Contractor’s Accident Prevention Plan)
DATE:
| Prepared by: |
| Project No: |
| Task Order/Contract No: |
Area/Bldg:
Work Scope/Description:
Primary Secondary
Emergency Contact Person(s)
Emergency Radio/Phone No:
Specific Work Location(s)
Various
Pre-job Walkthrough Conducted: Yes No
| Yes |
| No |
| Reference |
| Yes |
| No |
| Reference |
1.Radiological Area Work × ¤
| 10CFR 835 |
| 13. Electrical Hazard × ¤ □ |
29 CFR 1926, Subpart K
2. Hazardous Waste Operations × ¤
| 29 CFR 1910.120 |
| 14. Asbestos Work × ¤ □ |
29 CFR 1926.1101
3. Confined Spaces × ¤ □
| 29 CFR 1910 Subpart J |
| 15. Lead Work × ¤ □ |
29 CFR 1926.62
4. Hot Work × □
| 29 CFR 1926 Subparts F&J |
| 16. Hazardous Materials × |
29 CFR 1926 Subpart Z
5. Roof Work ¤
17. Respiratory Hazards ×
29 CFR 1926 Subpart E
6. Fall Hazards (>6 ft.) × □
| 29 CFR 1926 Subpart M |
| 18. Noise Dose × |
29 CFR 1910.95
7. Excavation/Trenching ¤ □
| 29 CFR 1926 Subpart P |
| 19. Heat Stress |
29 CFR 1926
8. Scaffolding × □
| 29 CFR 1926 Subpart L |
| 20. Demolition □ |
29 CFR 1926, Subpart T
9. Aerial Lifts × □
| 29 CFR 1926 Subpart N |
| × = Requires formal/special training |
¤ = Requires a permit/form/report
□ = Requires certification or competent/qualified person designation
10. Heavy Equipment × □
29 CFR 1926 Subpart O
11. Lock and Tag × ¤ □
29 CFR 1926 Subpart G
12. Site/Vehicle Traffic
29 CFR 1926 Subpart O
SPECIFIC HAZARD ANALYSIS AND SAFE WORK REQUIREMENTS
A detailed discussion of the unique hazards to the work activity/location, including those noted above, will be provided on the Activity Hazard Analysis (AHA). This discussion must include identification of the work activity, the specific hazards present, and the safe work requirements/controls (including PPE) to be used to alleviate/control the hazard(s).
MINIMUM DRESS/PPE REQUIREMENTS:
Substantial Footwear, Long Pants, Shirt with Sleeves
Does further evaluation of the job steps, associated hazards, or safety measures need to be performed? Yes No
Supervision:
Date:
| Activity Hazard Analysis - Continuation page |
| Project No: |
Task Order/Contract No:
COSR Signature:
COTR Signature:
AMD Safety Form-04 (Jan. 09)
CONTRACTOR ACCIDENT REPORT
CONTRACTOR EMPLOYEE’S NAME: ___________________________________________
Last
First
M.I.
NAME OF COMPANY: ________________________________________________________
ADDRESS: _______________________________________________________________
SUPERVISOR: _______________________________________________________________
DATE & TIME OF ACCIDENT: _______________________________________________
DATE & TIME FIRST REPORTED: _____________________________________________
LOCATION OF ACCIDENT: __________________________________________________
DESCRIPTION OF INJURIES_________________________________________________
MEDICAL SERVICES REQUIRED:_________YES________NO
NAME OF DOCTOR OR HOSPITAL:______________________________________________
ACCIDENT DETAILS (CONDITIONS, MACHINERY, EQUIPMENT, MATERIALS, WEATHER, OTHER
PERSONNEL INVOLVED) _____________________________________________________
WITNESSES _____________________________________________________________________________
Superintendent Signature Date COTR Signature
Date
Contractor Safety Representative Date COSR Signature
Date
(Original copy to Contractor, copy to CO, COTR, COSR) AMD Safety Form-05 (Jan. 09)
IMMEDIATE HAZARD REPORT
| Identified Hazard: |
| Date: |
| Name of Employees Removed from Area |
| Badge No. |
Recommended Corrective Action:
Action Taken
Hazard Resolved
□ YES □ NO
□ YES □ NO
| Signatures: |
| Date: |
Contractor’s Safety Representative:
COSR:
COTR:
AMD Safety Form-06 (Jan. 09)
CFMO/EMSS/Plant
Safety Inspection Log Sheet
Date/Time: ______________ If outdoors, weather & temp: _________________
Contractor: _______________
Project/Location:_______________________
Contract Number: _____________________________
Inspected by (COTR/COSR signature): _______________________________________
VIOLATION: OSHA
SAFETY PLAN
EPA
OTHER
Cite specific violation reference (i.e., OSHA 29 CFR 1926.100(a))
Contractor Safety Rep on jobsite (Y/N) _____
Contractor Superintendent on jobsite (Y/N) ____
Contractor Rep (not a subcontractor rep) who received hand-delivered violation from COTR:
Name: _________________________________Date/time:__________________________________
Remarks: ____________________________________________________________________________
Request corrective action in writing by (date): ______________________
Date/time that violation notice was hand delivered to Contracting Officer: _________
REINSPECTION DATE: __________________ VIOLATION: Corrected Failed:
Remarks: _____________________________________________________________________________
Request corrective action by (date):______________________
2nd REINSPECTION DATE: ___________ VIOLATION: Corrected Failed:
Date/time that contractor was notified that violation has been corrected: ___________________________
Date that “corrected” violation notice was hand delivered to Contracting Officer: ____________________
COTR’s Closeout signature: __________________________ Date: ________________
AMD Safety Form-07 (Jan. 09)
8. Safety Reporting
a. Every 30 days, the contractor shall furnish to the COSR
1. The total number of man-hours worked the previous 30 days
2. The cumulative number of man-hours worked from the contract notice to proceed
3. The total number of lost man-hours in the previous 30 days
a. If zero – report zero hours lost
4. The cumulative number of lost man-hours from the contract notice to proceed
a. If zero – report zero hours lost
Work Hours Reporting
Contract #
Reporting Period:
| Description |
| Man-Hours |
Total number of man-hours worked the previous 30 days
Cumulative number of man-hours worked from the contract notice to proceed (include the hours reported above)
Total number of lost man-hours in the previous 30 days
Cumulative number of lost man-hours from the contract notice to proceed (include the hours reported above)
_1453294493.unknown
_1453294494.unknown
_1453294492.unknown
_1453294491.unknown
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