Statement of Work - Attachment 14 - 01 35 26 - Attachment A - Accident Investigation Form (CIRS).pdf

Contractor Incident Report System (CIRS)

1. Contract Information Incident Information Prime Contractor:

Cage Code:

Contract Number:

Installation of Incident:

Task Order #:

Contracting Activity/ROICC Office:

Contractor Contact Information Name (Last, First):

Phone #:

Email Address:

Date Notified:

2. Incident Type (Please Check/Bold All That Apply) Assault/Violent Act Extreme Environmental Exposure Man over the side (No water entry)

Diving Falls, slip, trip, or bodily exertion Man Overboard - Water Entry

Electrical Shock/Burns Fires - All Types Material Handling Equipment

Equipment Installation/Repair Hazardous Material (any type) Ordnance-Related (Explosive)

Explosion, Non-Ordnance Industrial (Select Additional Below) Vehicle (Government or Private)

Industrial Incident Additional Information (Please Check/Bold All That Apply)

Confined Space Hand and Power Tools Work Platforms and Scaffolding

Demolition/Renovation Rigging Underground Construction, Shafts, and Caissons

Trenching/Entrapment Cranes and Hoisting Equipment Concrete, Masonry, Steel Erection and Residential Construction

Traffic Control Floating Plant and Marine Activities Tree Maintenance and Removal

Welding and Cutting Pressurized Equipment and System Airfield and Aircraft Operations

Control of Hazardous Energy Fall Protection

Date _____/_____/_____ Final Report Follow-up Report Initial Report

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3. General Information Incident Information Date of Accident:

Time of Accident:

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

Exact Location of Accident:

Were Hazardous Material(s) Involved Yes No

If Yes, Explain What Hazardous Materials Were Involved and Why:

Who Provided Clean-up? Onsite Base Public

Activity of the injured person at the time of incident:

Personal Protective Equipment: (Check/Bold Response)

List PPE Used:

Wrong PPE for job Not related to Mishap

Not Required Available and not used Available and used

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4. Fully Explain What Allowed or Caused the Incident: Incident Information

Direct Cause:

Indirect Cause:

Additional Action Taken: (Please Include a Begin Date and Est. End Date in Description)

Additional Action Taken: (Please Include a Begin Date and Est. End Date in Description) (Use the back of page if you need additional space)

5. Contributing Factors:

Was Visibility Restricted? Yes No

Distance Visibility was restricted:

Unit of Measure (Check/Bold): Feet Yards Meters Miles Nautical Miles

Visibility Restricted By: (Check/Bold all that apply)

Fog Smoke Rain Sleet Snow

Mist Dust Sandstorm Unknown Object Other:

Lighting Conditions at Site of Mishap:

(Please Check)

Adequate Inadequate Unknown

Was Noise Level a Factor:

(Please Check)

Yes No Unknown

Was Carbon Monoxide (CO) a Factor:(Please Check)

Yes No

If Yes CO Alarm Manufacturer:

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5. Contributing Factors: Continued Incident Information

Other Contributing Factors:

6. Attached Documents Attached Documents/Files Name/Description:

Date Added:

Uploaded By:

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1. Injured Data Person #

Age:

Gender:

(Check/Bold)

Male Female

Prime Contractor Company Name:

Subcontractor Company Name:

2. General Information Drug or Alcohol Involved: (Check/Bold all that apply)

None Unknown Alcohol Drugs Alcohol and Drugs

Who Provided First Aid? Onsite Base Public

Was Ergonomics a Factor: (Check/Bold) Yes No

Type of Ergonomic Injury: (Check/Bold All That Apply)

Lifting Positioning Bending Equipment Placement Office

Equipment Placement Industrial Repetitive Motion Impact Strain

3. Injury Illness/Fatality Information

Severity of Injury/Illness: (Check/Bold)

Where There Days Lost:

Where There Days Hospitalized:

Where There Days Restricted Duty:

Part of Body Affected:

Nature of Injury or Illness:

Event or Exposure:

Source of Injury or Illness:

General Location Description:

Injury Activity Code:

No Injury Non-Recordable Case Permanent Partial Disability Recordable First Aid Case Other Recordable Case Permanent Total Disability

Recordable Workday Case Involving Restricted Duty Temporary Disability Lost Workday Case Involving Days Away From Work Fatality

Contractor Incident Report System (CIRS) 5 douglas.tusing Typewritten Text (if applicable) douglas.tusing Typewritten Text

4. License Person #

Are Appropriate License and Certification/Medical Current: (Check/Bold) Yes No

Describe or Explain:

Attach Image of License or Certification

5. Training

Was all the contract-required training provided to the employee: (Check/Bold) Yes No

Explain:

6. Attached Documents

Attached Documents

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(if applicable)

1. Involved Person Data Property Damage

Age:

Gender:

Male Female

Contractor:

Contractor:

2. Attached Documents

Attached Documents

3. Property Damaged

Was Anyone Injured: Yes No

Was A Government Motor Vehicle Involved: Yes No

Property Type

Property ID #

Detailed Description

Property Owned By

Estimated Cost USD

Lost Use Days

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4. License Property Damage

Are Appropriate License and Certification/Medical Current: (Check/Bold) Yes No

Describe or Explain:

Attach Image of License or Certification

5. Training

Was all the contract-required training provided to the employee? (Check/Bold) Yes No

Explain:

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CONTRACTOR INCIDENT REPORT SYSTEM (CIRS) INSTRUCTIONS

Complete Only Sections Appropriate to Incident (Rev. 03/11).

NOTE: THE ATTACHED CIRS 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 pages 5-6. A report needs to be completed for all OSHA recordable accidents and property damage cases. Please type or print legibly. Appropriate items shall be Checkd/Bolded, 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: (Check/Bold) 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.

Incident Information Section 1 Contract Information – Incident Information Prime Contractor: Name as it appears on contract documents.

Cage Code: If known.

Contract Number: Number as it appears on the contract documents.

Installation: Name of installation where incident occurred.

Task Order #: Insert number if applicable.

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.).

Contractor Contact Information: (Contractor point of contact information for the individual responsible for completing the form) Self Explanatory

Section 2 Incident Type: Check/Bold most applicable category, if you select Industrial you must Check/Bold at least one additional category from the Industrial Incident Additional Information Section.

Section 3 General Information Incident Information 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.).

Describe the Accident in Detail in your words: 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 4 (Fully Explain What Allowed or Caused the Incident - Incident Information) below before completing.

Exact Location of Accident: Enter facts needed to locate the accident scene (e.g. installation/project name, building/room number, street, direction and distance from closest landmark, etc.).

Were Hazardous Material(s) Involved Yes No

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If Yes, Explain What Hazardous Materials Were Involved and Why: Check or Bold appropriate block and list name(s) and quantities of hazardous materials spilled/released during the mishap. List why the hazardous chemicals were being used.

Activity at the time of incident: What type of work/task was being performed by the injured when the injury took place or property damage occurred.

Personal Protective Equipment– Check/Bold appropriate items 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.)

Section 4 Fully Explain What Allowed or Caused the Incident - Incident Information Direct Cause(s): The direct cause is that single factor which most directly lead 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.)

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).

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

Please Include a Begin Date and Estimated Completion Date in Description

(1) Begin: Enter the date when the corrective action(s) identified above will begin.

(2) Est. End Date - Enter the date when the corrective action(s) identified above will be completed.

Section 5 Contributing Factors Incident Information: Check/Bold appropriate items fill in information where required Other Contributing Factors: Describe in detail any additional contributing factors not listed in previous information provided.

Section 6 Attached Documents: Provide the appropriate information for each document/file attached or uploaded.

Injured Data Person # Complete Pages 5 and 6 for each injured person At the upper right hand corner of page 5 and 6 differentiate between each person by using a numerical value (e.g. Person #1, Person #, Person #3, etc.)

Section 1 Injured Data: Fill in all applicable information, Check/bold appropriate responses.

Section 2 General Information:

Check/bold appropriate responses

Section 3 Injury/Illness Fatality Information: Check/bold appropriate responses Part of Body 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.).

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Nature of Injury/Illness: Describes the manner in which the injury or illness was inflicted or produced. It attempts to answer the broad question of “how” work injuries and illnesses occurred. (e.g. Fall, Struck By, Caught By, Repetitive Motion, Rubbed or Abraded By, etc.)

Event or Exposure: Describes what was produced by the injury or illness was produced or inflicted. (e.g. Infectious Parasitic Diseases, Traumatic Injuries and Disorders, Open Wounds, Burns, Intracranial Injuries, etc.)

Source of Injury Illness: Identifies the object, substance, bodily motion, or exposure, which directly produced or inflicted the previously identified injury or illness. (e.g. Acids, Chemical Products, Furniture and Fixtures, Machinery, Structures and Surfaces, Tools Instruments and Equipment, etc.)

General Location Description: Describes where the injury occurred (e.g. Industrial Facilities, Operational Industrial Building Plant , Roadway, etc.)

Injury Activity Code: Describes what the injured person was doing when the injury occurred. (e.g. Operating Type of Equipment, Construction Activity Being Performed, Industrial Operation Being Conducted, etc.)

Section 4 License:

Are Appropriate License and Certification/Medical Current: Did the injured employee have the appropriate license/certification or medical evaluations completed to conduct the work/task being performed.

Describe/Explain: Describe the required (licensing/certification/medical evaluation) for job/task being performed, date when license was issued, and expiration date. (e.g. “Powdered Actuated Tools, Hilti DX-350, License issued 11/29/2011, expires 3-years from issue date.” “Respirator Semi Annual Medical Evaluation, conducted 12/30/2011, expires on 12/30/2013”, etc.)

Attach Image of License or Certification: Self-Explanatory

Section 5 Training:

Was all the contract-required training provided to the employee: Self-Explanatory

Explain: If no, to the previous questions explain why the employee was not trained.

Section 6 Attached Documents:

Self-Explanatory use this for photos, drawings, diagrams, or other relevant documents.

Property Damage Section 1 Involved Person Data: Fill in all applicable information, Check/bold appropriate responses.

Section 2 Attached Documents:

Self-Explanatory use this for photos, drawings, diagrams, or other relevant documents.

Section 3 Property Damaged:

Check/bold appropriate responses. Other Headings Self-Explanatory.

Section 4 License:

Are Appropriate License and Certification/Medical Current: Did the equipment operator have the appropriate license/certification or medical evaluations completed to conduct the work/task being performed.

Describe/Explain: Describe the required (licensing/certification/medical evaluation) for job/task being performed, date when license was issued, and expiration date. (e.g. “State Issued Driver, License issued 11/29/2011, expires on MM/DD/YYY)” “Scissor Lift, JLG Model 260MRT conducted 12/30/2011, does not expire.”)

Attach Image of License or Certification: Self-Explanatory

Section 5 Training:

Was all the contract-required training provided to the employee: Self-Explanatory

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