Technical Eval Attachment - Service Order Form-v9_20250614 C.pdf
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- PANHES25P0000001179
About this file
The document contains two key federal contract-related forms: a Complexity Determination Sheet and an Activity Hazard Analysis (AHA) template for a service order.
The Complexity Determination Sheet is a matrix for contractors to assess the complexity of a service order across multiple factors, including coordination requirements, utility outage likelihood, unknown conditions, regulatory interactions, and urgency. The form allows marking complexity levels as low, medium, or high for each factor, with corresponding required documentation. The AHA template is a risk assessment tool that enables detailed safety analysis, featuring a Risk Assessment Code (RAC) matrix to evaluate potential job hazards by severity and probability. The overall risk assessment is categorized from extremely high (E) to low (L), helping contractors systematically identify and mitigate potential safety risks for a specific service order (numbered XYZ-KTR-100).
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Text version
FACTOR LOW MEDIUM HIGH
Low Medium High Scope of Work Yes Yes Yes Pictures Yes Yes Yes Cost Proposals Yes Yes Yes SSAPP Yes Yes Yes AHA Yes Yes Yes Manufacturers Data A/E Yes Yes
Table of Contents Yes Yes Work Plan Narrative Yes Yes Manufacturers Data A/R Yes Yes Sketches Yes Yes Detailed Drawings A/R Yes Project Specific Schedule A/R Yes Specifications A/R Yes Project Specific Quality Control Plan A/R Yes Work Plan Review Meeting/Pre-Con A/R Yes Site Investigation Report A/R Yes
X
X
X
X
COMPLEXITY DETERMINATION SHEET
*Complexity
Logistical difficulty X
TASK COMPLEXITY DETERMINATION MATRIX
Instructions: Contractor should initially estimate the complexity of the service order. PLACE AN "X" IN THE BOX FOR LOW, MEDIUM, OR HIGH FOR EACH FACTOR. Depending on complexity, ensure the cooresponding required content is submitted with service order.
This is meant to be a guide only. Final determination of complexity as well as what is required to be included with each service order will be determined by USACE.
X
Coordination with other trades, other contractors, customer, or owner/operators
Likelihood of outage of utilities and/or systems
Level of unknowns or undefined conditions
Level of interaction with regulatory entities
Level of urgency
WORK PLAN REQUIRED FOR MEDIUM AND HIGH COMPLEXITY
OVERALL COMPLEXITY OF TASK
X
Required Content
AHA Number M SERVICE ORDER NUMBER XYZ-KTR-100 Rev #
TASK ORDER SAFETY MANAGER NAME:
CONTRACT NUMBER:
TASK ORDER/DELIVERY #:
PRIME CONTRACTOR:
SUBCONTRACTOR:
JOBSITE SAFETY & HEALTH OFFICER: E H
CONTRACTOR QUALIFIED PERSON: H H
CONTRACTOR COMPETENT PERSON: M M
L L
L = LOW RISK (ET or PAR)
Contract #
Activity Hazard Analysis (AHA)
Catastrophic E H
Risk Assessment Code (RAC) Matrix
Overall Risk Assessment Code (RAC) - Use Highest RAC from Tasks Below
M
Severity
Probability Contractor Name
“Severity” is the outcome/degree if an incident, near miss, or accident did occur and identified as: Catastrophic, Critical, Marginal, or Negligible after controls are in place
“Probability” is the likelihood to cause an incident, near miss, or accident did occur and identified as: Frequent, Likely, Occasional, Seldom, or Unlikely after controls are put in place.
E = EXTREMELY HIGH (PWO/OICC/ROICC)
Identify the RAC (Probability/Severity) as E, H, M, or L for each “Hazard”. Place the highest RAC at the top of AHA. This is the overall risk assessment code for this activity
H = HIGH RISK (FEAD DIRECTOR)
M = MODERATE RISK (CM or ET or PAR)
Negligible M L L
RAC CHART and ACCEPTANCE BY GOVERNMENT DESIGNATED AUTHORITY
L
H M
Job Steps Hazards Controls RAC E
Seldom Unlikely
Review each “Hazard” with identified safety “Controls” and determine (RAC)
Critical E M L
Marginal H L L
Frequent Likely Occasional
File details come from the government source that posted it. Updated .