W911SA25QA133 Technical Exhibits Attachments 06-01 through 06-08.pdf

9.

10.

k2enhacm Sticky Note Marked set by k2enhacm

9.

10.

k2enhacm

Sticky Note

Marked set by k2enhacm

TABLE OF CONTENTS

SECTION A – SEE SF1449

SECTION B – SEE SF1449

SECTION C – DESCRIPTIONS AND SPECIFICATIONS – PERFORMANCEWORK STATEMENT

Section C 0100000 FIS General Information Region 5

Section C 0200000 Management and Administration Region 5

Section C 1502000 Facility Investment Services Region 5

Section C 1800000 Environmental Services Region 5

SECTION D – NOT USED

SECTION E – SEE SF1449

SECTION F – DELIVERIES OR PERFORMANCE

SECTION G – SEE SF1449

SECTION H – SEE SF1449

SECTION I – SEE SF1449

SECTION J – LIST OF DOCUMENTS, EXHIBITS, AND OTHER ATTACHMENTS

Section J Consolidated Index

Section J 0200000 Management and Administration

J-0200000-01 ACRONYMS

J-0200000-02 Index of Wage Determinations

J-0200000-03 References, Instructions, Directives

J-0200000-04 INVOICING PROCEDURES

J-0200000-05 FORMS

Work Request, Est & Completion Form

Spill Report Form

J-0200000-06 Gov't furnished property, Materials, & Services

J-0200000-07 & J-1800000 ELINS Region 5

J-0200000-08 Site Index

Section J 1502000

J-1502000-02 Site Map Index

J-1502000-03

J-1502000-04

J-1502000-05

J-1502000-06

J-1502000-07

J-1502000-08

J-1502000-09

J-1502000-10

J-1502000-11

J-1502000-12

J-1502000-13

J-1502000-14

J-1502000-15

J-1502000-16

J-1502000-17

J-1502000-18

J-1502000-19

J-1502000-20

J-1502000-21

J-1502000-22

J-1502000-23

J-1502000-24

J-1502000-25

J-1502000-26

J-1502000-27

J-1502000-28

J-1502000-29

J-1502000-30

J-1502000-31

J-1502000-32

J-1502000-33

J-1502000-34

J-1502000-35

J-1502000-36

J-1502000-37

J-1502000-38

J-1502000-39

J-1502000-40

J-1502000-41

J-1502000-42

J-1502000-43

J-1502000-44

J-1502000-45

J-1502000-46

J-1502000-47

J-1502000-48

J-1502000-49

J-1502000-50

J-1502000-51

J-1502000-52

J-1502000-53

J-1502000-54

J-1502000-55

J-1502000-56

J-1502000-57

J-1502000-58

J-1502000-59

J-1502000-60

J-1502000-61

J-1502000-63

J-1502000-64

J-1502000-65

J-1502000-66

J-1502000-68

J-1502000-69

J-1502000-70

J-1502000-71

J-1502000-72

J-1502000-73

J-1502000-74

J-1502000-75

SECTION K - SEE SF1449

SECTION L - SEE SF1449

SECTION M - SEE SF1449

Existing Equipment Information:

Manufacturer:

Sections A, B, C, D, and E required for ALL estimates

B

Priority:

Building: Funding Source:

63d Service Request Summary and Description:

Order Value:

CSS W/O:

Work Request, Estimate and Completion Form

Contractor required to provide manufacturer, model and serial number for all components being serviced, repaired and/or replaced.

A

Region: Order Date:

Contract: Order Value:

Service Request Number: Estimate Date:

FACID:

C

D

Total Material $ -

KTR Provided Scope of Work/Repair Requirement:

Manufacturer:

Model:

Serial Number:

E

Material and Labor:

Model:

Estimate Date:

FACID: Priority:

Replacement Equipment Information:

Building: Funding Source:

This section required to be submitted when a scope change is required.

F

Scope Change Description:

Contract:

Serial Number:

G Repair Completion Date:

Government Signature Prime Contractor Signature

Original Order Value:

Scope Change Request:

New Estimated Total Cost:

Total Labor Total Estimated Cost

This section required to be submitted when repair is complete.

Region: Order Date:

Region:

Order Date:

Contract:

Order Value:

Service Request Number:

FACID:

Building:

Estimate Date:

Priority:

Funding Source:

63d Service Request Summary and DescriptionB:

Manufacturer:

Model:

Serial Number:

Manufacturer_2:

Model_2:

Serial Number_2:

KTR Provided Scope of WorkRepair RequirementD:

Material and LaborE:

fill_29:

fill_30:

fill_31:

F:

fill_32:

fill_33:

fill_34:

Region_2:

Contract_2:

CSS WO:

FACID_2:

Building_2:

Order Date_2:

Order Value_2:

Estimate Date_2:

Priority_2:

Funding Source_2:

Repair Completion Date:

ELEVATOR INSPECTION REPORT

(Including Escalators and Dumbwaiters) (Read instructions on reverse before preparing report)

BUILDING

STATECITYSTREET ADDRESS

DATE INSPECTION ORDERED

MECHANIC'S SIGNATURE

INSPECTOR'S SIGNATURE INSPECTOR'S TITLE

B. LIST REPAIR AND MAINTENANCE ITEMS BELOW THAT ARE OUTSIDE THE SCOPE OR RESPONSIBILITY OF THE BUILDINGS MANAGER OR CUSTODIAN.

BUILDINGS MANAGER'S SIGNATURE DATE

DATE

All elevators, escalators, and dumbwaiters in this building have been inspected by the undersigned inspector on the date noted, and were found to be in a satisfactory condition, except as noted below.

A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING.

(List items below that can be properly performed by force account.)*

THE WORK DESCRIBED ABOVE HAS BEEN COMPLETED, AND THE EQUIPMENT IS READY FOR REINSPECTION, IF REQUIRED

DATE INSPECTION DATE INSPECTION

CERTIFICATES SIGNEDSTARTED:

COMPLETED:

PASSENGER FRT. OR SERV. ESCALATOR DUMBWAITER

REGION

NUMBER OF UNITS IN BUILDING

GSA FORM 376 (11-67)* (Use reverse when more space is required.)GENERAL SERVICES ADMINISTRATION

INSTRUCTIONS

TO

a. Design and Construction Division

b. Buildings Manager - to be forwarded through the regional Buildings Management Division. (One copy to be signed by the mechanic and the Buildings Manager upon completion of the work listed in Section A of the report, and returned to the inspector.

As determined by regional requirements

NUMBER OF COPIES

1. A separate report shall be made for each building for which PBS is responsible for elevator inspections.

2. Distribution of copies:

GSA FORM 376 BACK (11-67)

ELEVATOR INSPECTION REPORT

(Including Escalators and Dumbwaiters)

(Read instructions on reverse before preparing report)

BUILDING

STATE

CITY

STREET ADDRESS

DATE INSPECTION ORDERED

MECHANIC'S SIGNATURE

INSPECTOR'S SIGNATURE

INSPECTOR'S TITLE

B. LIST REPAIR AND MAINTENANCE ITEMS BELOW THAT ARE OUTSIDE THE SCOPE OR RESPONSIBILITY OF THE BUILDINGS MANAGER OR CUSTODIAN.

BUILDINGS MANAGER'S SIGNATURE

DATE

DATE

All elevators, escalators, and dumbwaiters in this building have been inspected by the undersigned inspector on the date noted, and were found to be in a satisfactory condition, except as noted below.

A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING.(List items below that can be properly performed by force account.)*

THE WORK DESCRIBED ABOVE HAS BEEN COMPLETED, AND THE EQUIPMENT IS READY FOR REINSPECTION, IF REQUIRED

DATE INSPECTION

DATE INSPECTION CERTIFICATES SIGNED

STARTED:

COMPLETED:

PASSENGER

FRT. OR SERV.

ESCALATOR

DUMBWAITER

REGION

NUMBER OF UNITS IN BUILDING

GSA FORM 376 (11-67)

* (Use reverse when more space is required.)

GENERAL SERVICES ADMINISTRATION

INSTRUCTIONS

TO

a. Design and Construction Division

b. Buildings Manager - to be forwarded through the regional Buildings Management Division. (One copy to be signed by the mechanic and the Buildings Manager upon completion of the work listed in Section A of the report, and returned to the inspector.

As determined by regional requirements 2

NUMBER OF COPIES

1. A separate report shall be made for each building for which PBS is responsible for elevator inspections. 2. Distribution of copies:

GSA FORM 376 BACK (11-67)

8.2.0.3062.1.452232.445150

BUILDING:

STREET ADDRESS:

INSPECTOR'S TITLE:

A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING. (List items below that can be properly performed by force account.)*:

B. LIST REPAIR AND MAINTENANCE ITEMS BELOW THAT ARE OUTSIDE THE SCOPE OR RESPONSIBILITY OF THE BUILDINGS MANAGER OR CUSTODIAN.:

CITY:

STATE:

REGION:

DATE INSPECTION ORDERED. Enter 2 digit month, 2 digit day and 4 digit year.:

DATE. Enter 2 digit month, 2 digit day and 4 digit year.:

DATE. Enter 2 digit month, 2 digit day and 4 digit year.:

DATE INSPECTION CERTIFICATES SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.:

DATE INSPECTION STARTED. Enter 2 digit month, 2 digit day and 4 digit year.:

DATE INSPECTION COMPLETED. Enter 2 digit month, 2 digit day and 4 digit year.:

NUMBER OF UNITS IN BUILDING. PASSENGER:

NUMBER OF UNITS IN BUILDING. FRT. OR SERV.:

NUMBER OF UNITS IN BUILDING. ESCALATOR:

NUMBER OF UNITS IN BUILDING. DUMBWAITER:

BUILDINGS MANAGER'S SIGNATURE. DIGITAL SIGNATURE.:

A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING. (List items below that can be properly performed by force account.)* Continued from page 1.:

Please wait...

If this message is not eventually replaced by the proper contents of the document, your PDF viewer may not be able to display this type of document.

You can upgrade to the latest version of Adobe Reader for Windows®, Mac, or Linux® by visiting http://www.adobe.com/go/reader_download.

For more assistance with Adobe Reader visit http://www.adobe.com/go/acrreader.

Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.

GSA 55 (REV. 7/2002)

GENERAL SERVICES ADMINISTRATION

CERTIFICATE OF ELEVATOR INSPECTION

GENERAL SERVICES ADMINISTRATION - PUBLIC BUILDINGS SERVICE

INSPECTED

DATE

ELEVATOR MECHANIC

ELEVATOR ENGINEER

ACKNOWLEDGMENT OF ELEVATOR INSPECTION CERTIFICATE

CERTIFICATION

I CERTIFY THAT I RECEIVED THE ORIGINAL OF THIS CERTIFICATE OF INSPECTION (GSA FORM 55) THAT IT HAS BEEN COUNTERSIGNED BY THE ELEVATOR MECHANIC, AND IS POSTED IN THE CAR OF THE ELEVATOR TO WHICH IT PERTAINS.

THE ORIGINAL OF THIS CERTIFICATE INSTRUCTS THE OPERATOR, IN CASES OF ELEVATOR TROUBLE OR EMERGENCY, TO CALL:

GENERAL SERVICES ADMINISTRATION

GSA 55A (REV. 7/2002)

11.0.0.20130303.1.892433.887364

Building:

ElevatorNumber:

TypeDuty:

City:

Capacity:

Passengers:

CallNumber:

Elevator Mechanic :

Elevator Mechanic :

Elevator Mechanic :

Elevator Mechanic :

Elevator Engineer:

Elevator Engineer:

Elevator Engineer:

Elevator Engineer:

Row 1 of 4. Date. Enter 2 digit month, 2 digit day and 4 digit year.:

Row 2 of 4. Date. Enter 2 digit month, 2 digit day and 4 digit year.:

Row 3 of 4. Date. Enter 2 digit month, 2 digit day and 4 digit year.:

Row 4 of 4. Date. Enter 2 digit month, 2 digit day and 4 digit year.:

THE ORIGINAL OF THIS CERTIFICATE INSTRUCTS THE OPERATOR, IN CASES OF ELEVATOR TROUBLE OR EMERGENCY, TO CALL: :

THE ORIGINAL OF THIS CERTIFICATE INSTRUCTS THE OPERATOR, IN CASES OF ELEVATOR TROUBLE OR EMERGENCY, TO CALL: :

THE ORIGINAL OF THIS CERTIFICATE INSTRUCTS THE OPERATOR, IN CASES OF ELEVATOR TROUBLE OR EMERGENCY, TO CALL: :

1. Date. Enter 2 digit month, 2 digit day and 4 digit year.:

SuperSign:

ENG FORM 3394, AUG 2021 PREVIOUS EDITIONS ARE OBSOLETE. Page of

U.S. Army Corps of Engineers (USACE)

MISHAP NOTIFICATION AND INVESTIGATION

For use of this form, see instructions in the attachments and USACE ER 385-1-99; the proponent agency is CESO.

Requirement Control Symbol

RCS-CESO-21-0001

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority 10 U.S.C. 7013, Secretary of the Army; 5 U.S.C. 7902, Safety Programs; Public Law 91-596, Occupational Safety and Health Act of 1970; DoD Instruction 6055.1, DoD Safety and Occupational Health Program; Army Regulations 385-10, Army Safety Program;

DoD Instruction 6055 .07, Mishap Notification, Investigation, Reporting, and Record Keeping; and E.O. 9397 (SSN), as amended.

Principal Purpose Information collected is to provide the USACE leaders, soldiers, families and civilians in injury, illness, and loss data to effectively manage its safety and occupational health program.

Routine Uses In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b) as follows: To the Department of Labor, the Federal Aviation Agency, the National Transportation Safety Board, and to Federal, State, and local agencies and applicable civilian organizations, such as the National Safety Council, for use in a combined effort of accident prevention. In some cases, data must also be disclosed to an employee's representative under the provisions of 29 CFR

1960.29. Records will be made available consistent with applicable laws and regulations. Information will be withheld from the public only if authorized by 5 U.S.C. Section 552 (Freedom of Information Act (FOIA), 5 U.S.C. 552a (Privacy Act)), or other statutory or regulatory authority.

Disclosure Failure to provide all the required information on the report may result in the rejection of report submission.

1. WHO IS REPORTING MISHAP

a. Name: b. Phone number:

c. Email address: d. Signature:

e. Report type:

1. Near Miss Report. (No injury/illness, or property damage. Complete all fields with underlined text.) Date:

2. Initial Accident Report. (For accident notification within 24 hrs, Complete all fields with underlined text.) Date:

3. Final Accident Report. (For reporting findings from accident investigation, complete full form.) Date:

f. Mishap Type. (Check all that apply)

Fatality Injury/Illness Property Damage Near Miss

g. Were any of the following items associated with the mishap ? (If yes, check all that apply)Yes No

Electrical and/or Hazardous Energy Working at Heights Diving

Load Handling Equipment or Rigging

Occupational Health Exposure

2. WHO WAS INVOLVED IN THIS MISHAP?

a. Name:

b. Personnel Classification: c. Time employee began work:

d. Gender: e. Date of birth (for Government personnel only): f. Age:

g. Date hired: h. Primary language:

i. Is individual a supervisor? Yes No j. Duty status at time of mishap: k. Years experience in job:

l. What was individual doing when mishap occurred? (Select activity from the drop downs below.)

1. General activities: 2. Vehicle/Equipment/Vessel:

3. Sports/Recreation: 4. Other not listed:

m. Did individual utilize all OSHA/EM 385-1-1 required Personal Protective Equipment (PPE) for activity? Yes No N/A

If no, identify missing PPE:

n. Was a Personal Flotation Device used? Yes No N/A o. Was a seat belt used? Yes No N/A

ENG FORM 3394, AUG 2021 Page of

p. Government personnel only:

4. Center/Division/Lab: 5. District:

1. Prime Contractor name:

q. Contractor personnel only:

2. Contract number: 3. Contract type: 4. Funding type:

Other not listed:

r. If mishap occurred on a contractor site, provide the following:

1. Employer/Contractor name:

3. Grade:2. Rank:

2. Individual's occupation/trade:

1. Job series:

h. If treatment was given away from the work-site, where was it given? (For Government Personnel Only)

j. Estimated days away from work: k. Estimated days of restricted/transferred duty:

Was OSHA notified? If yes, how many nights? Yes Noi. Was employee hospitalized as an in-patient? Yes No

Country:Zip:State: City:

Address:

Treatment facility name:

g. Was employee treated in an emergency room ? Yes No N/Af. Was treatment given away from work site? Yes No

Source of injury/illness: Cause of injury/illness:

Primary body part affected:

c. Identify body part(s) affected by injury/illness:

b. Type of Injury/Illness:a. Severity of injury/illness?

Secondary body part affected:

d. Identify cause and source of injury/illness:

If yes, provide name of physician or health care professional provider?

e. Was employee treated by a physician or health care professional provider? Yes No

Note: OSHA requires reporting all work-related fatalities within 8 hours and in-patient hospitalizations, amputations and loss of an eye within 24 hours to OSHA.

3. WHAT TYPE OF INJURY/ILLNESS OCCURRED?

4. WHAT HAPPENED?

a. What was the primary activity occurring at the time of the mishap?

Other, not listed:

b. What happened? Provide a detailed description of the mishap. (Do not include any personally identifiable information (name, etc.).)

Note: Provide supporting photos, charts, diagrams, etc. with this report.

c. What other organizations or agencies have been notified about this mishap?

b. USACE Office/Program/Project name:

a. List all property/material involved in the mishap. (Include damaged and undamaged property.)

i. Type of item:

Item A Item B Item C

ii. Name of item(s):

iv. Ownership of item:

v. Dollar cost of damage:

a. Date the mishap occurred: b. Time mishap occurred:

c. What day did mishap occur on? d. What period of day did mishap occur?

a. Did the mishap occur on a military Base/Post? Yes No

c. Select the location type most closely associated with the mishap:

d. Identify exact location where mishap occurred:

e. Latitude: f. Longitude:

iii. Collision type:

Country:Zip:State: City:

Address:

5. WHAT TYPE OF PROPERTY/MATERIAL WAS INVOLVED?

6. WHEN DID THE MISHAP OCCUR?

7. WHERE DID THE MISHAP OCCUR?

8. WHY DID THE MISHAP OCCUR? (Recommend completing this section for Near Misses.)

A. Performance Causal Factors

2. Describe action(s) taken, anticipated or recommended to eliminate cause(s):

If yes, select the error that contributed most to the mishap:

1. Did a problem with resources contribute to this mishap occurring?

1. Did a problem with performance contribute to this mishap occurring? Yes No

Yes No

B. Support Causal Factors

C. Standards/Policy/Planning Causal Factors

1. Did an organizational standard/policy/or plan contribute to this mishap occurring?

2. Was a written Activity Hazard Analysis (AHA) or equivalent completed and accepted by Government Designated Authority (GDA) for task(s) being performed at time of mishap? (If yes, attach a copy to this report)

If yes, was the AHA available and used by worker?

3. Was a written work plan (critical lift plan, fall protection plan, etc.) required, completed and accepted by the GDA for task(s) being performed at time of mishap?

If yes, was the plan available and used by worker?

4. Describe action(s) taken, anticipated or

1. Did any leader/supervisory mistake/task error contribute to this mishap occurring?

1. Did any individual mistakes/task errors contribute to this mishap occurring?

4. Describe action(s) taken, anticipated or

3. Describe action(s) taken, anticipated or

1. Did any material failure contribute to this mishap occurring?

1. Did a problem with training contribute to this mishap occurring?

If yes, select type of training: Classroom On the jobCertification/License

Other, describe:

What was date of most recent training?

2. Which failure is most closely associated with the material failure/malfunction?

1. Did any physical environment contribute to this mishap occurring?

2. Was individual trained to perform the activity/task?

3. Describe action(s) taken, anticipated or

2. Did the safety climate/culture contribute to the mishap?

3. Did challenges with teamwork contribute to the mishap?

D. Training Causal Factors

E. Leader/Supervisor Causal Factors

F. Individual Causal Factors

G. Physical Environment Causal Factors

H. Material Causal Factors

I. Environmental Causal Factors

If yes, select the factor that contributed most to the mishap:

1. Did any environmental condition contribute to this mishap occurring?

recommended to eliminate hazard:

If yes, describe:

1. Did the design of the facility/building contribute to the mishap?

J. Facility/Building Design

b. Who is responsible for the corrective action plan?

a. Have all corrective action(s) to prevent mishap recurrence been completed?

c. What date will/have all corrective action(s) be/been completed by:

d. Additional information:

recommended to eliminate hazard(s):

If yes, describe the hazard(s):

1. Did a hazard(s) contribute to the mishap?

K. Existing Hazard

9. Corrective Action plan

10. Additional Information

ENG FORM 3394, AUG 2021

PREVIOUS EDITIONS ARE OBSOLETE.

Page of

ENG FORM 3394, AUG 2021

Page of

U.S. Army Corps of Engineers (USACE)

MISHAP NOTIFICATION AND INVESTIGATION

For use of this form, see instructions in the attachments and USACE ER 385-1-99; the proponent agency is CESO.

Requirement Control Symbol RCS-CESO-21-0001

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority 10 U.S.C. 7013, Secretary of the Army; 5 U.S.C. 7902, Safety Programs; Public Law 91-596, Occupational Safety and Health Act of 1970; DoD Instruction 6055.1, DoD Safety and Occupational Health Program; Army Regulations 385-10, Army Safety Program;

DoD Instruction 6055 .07, Mishap Notification, Investigation, Reporting, and Record Keeping; and E.O. 9397 (SSN), as amended.Principal Purpose Information collected is to provide the USACE leaders, soldiers, families and civilians in injury, illness, and loss data to effectively manage its safety and occupational health program.Routine Uses In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b) as follows: To the Department of Labor, the Federal Aviation Agency, the National Transportation Safety Board, and to Federal, State, and local agencies and applicable civilian organizations, such as the National Safety Council, for use in a combined effort of accident prevention. In some cases, data must also be disclosed to an employee's representative under the provisions of 29 CFR

1960.29. Records will be made available consistent with applicable laws and regulations. Information will be withheld from the public only if authorized by 5 U.S.C. Section 552 (Freedom of Information Act (FOIA), 5 U.S.C. 552a (Privacy Act)), or other statutory or regulatory authority.Disclosure Failure to provide all the required information on the report may result in the rejection of report submission.

1. WHO IS REPORTING MISHAP

e. Report type:

f. Mishap Type. (Check all that apply)

g. Were any of the following items associated with the mishap ? (If yes, check all that apply)

2. WHO WAS INVOLVED IN THIS MISHAP?

i. Is individual a supervisor?

l. What was individual doing when mishap occurred? (Select activity from the drop downs below.)

m. Did individual utilize all OSHA/EM 385-1-1 required Personal Protective Equipment (PPE) for activity?

n. Was a Personal Flotation Device used?

o. Was a seat belt used?

p. Government personnel only:

q. Contractor personnel only:

r. If mishap occurred on a contractor site, provide the following:

h. If treatment was given away from the work-site, where was it given? (For Government Personnel Only)

Was OSHA notified?

i. Was employee hospitalized as an in-patient?

g. Was employee treated in an emergency room ?

f. Was treatment given away from work site?

c. Identify body part(s) affected by injury/illness:

d. Identify cause and source of injury/illness:

e. Was employee treated by a physician or health care professional provider?

Note: OSHA requires reporting all work-related fatalities within 8 hours and in-patient hospitalizations, amputations and loss of an eye within 24 hours to OSHA.

3. WHAT TYPE OF INJURY/ILLNESS OCCURRED?

4. WHAT HAPPENED?

Note: Provide supporting photos, charts, diagrams, etc. with this report.

a. List all property/material involved in the mishap. (Include damaged and undamaged property.)

i. Type of item:

Item A

Item B

Item C

ii. Name of item(s):

iv. Ownership of item:

v. Dollar cost of damage:

a. Did the mishap occur on a military Base/Post?

Other not listed:

Other not listed:

iii. Collision type:

5. WHAT TYPE OF PROPERTY/MATERIAL WAS INVOLVED?

6. WHEN DID THE MISHAP OCCUR?

7. WHERE DID THE MISHAP OCCUR?

8. WHY DID THE MISHAP OCCUR? (Recommend completing this section for Near Misses.)

A. Performance Causal Factors

1. Did a problem with resources contribute to this mishap occurring?

1. Did a problem with performance contribute to this mishap occurring?

B. Support Causal Factors

C. Standards/Policy/Planning Causal Factors

1. Did an organizational standard/policy/or plan contribute to this mishap occurring?

2. Was a written Activity Hazard Analysis (AHA) or equivalent completed and accepted by Government Designated Authority (GDA) for task(s) being performed at time of mishap? (If yes, attach a copy to this report)

If yes, was the AHA available and used by worker?

3. Was a written work plan (critical lift plan, fall protection plan, etc.) required, completed and accepted by the GDA for task(s) being performed at time of mishap?

If yes, was the plan available and used by worker?

1. Did any leader/supervisory mistake/task error contribute to this mishap occurring?

1. Did any individual mistakes/task errors contribute to this mishap occurring?

1. Did any material failure contribute to this mishap occurring?

1. Did a problem with training contribute to this mishap occurring?

If yes, select type of training:

1. Did any physical environment contribute to this mishap occurring?

2. Was individual trained to perform the activity/task?

2. Did the safety climate/culture contribute to the mishap?

3. Did challenges with teamwork contribute to the mishap?

D. Training Causal Factors

E. Leader/Supervisor Causal Factors

F. Individual Causal Factors

G. Physical Environment Causal Factors

H. Material Causal Factors

I. Environmental Causal Factors

1. Did any environmental condition contribute to this mishap occurring?

1. Did the design of the facility/building contribute to the mishap?

J. Facility/Building Design

a. Have all corrective action(s) to prevent mishap recurrence been completed?

1. Did a hazard(s) contribute to the mishap?

K. Existing Hazard

9. Corrective Action plan

10. Additional Information

1.0 darwin.chen@usace.army.mil

2021-06-28

Forms Design Team

Darwin Chen

2021-07-30

MISHAP NOTIFICATION AND INVESTIGATION

MISHAP NOTIFICATION AND INVESTIGATION

PrintButton1:

saveas:

EmailSubmitButton1:

currentPage:

pageCount:

10. Additional Information:

repSignature:

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

CheckBox1: 0

DateField1:

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

Yes: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

No: 0

DropDownList1:

DateTimeField1:

DateField2:

yes: 0 yes: 0 yes: 0 yes: 0 no: 0 no: 0 no: 0 no: 0 na: 0 na: 0 na: 0 na: 0

TextField3:

TextField2:

63d RD Environmental Division

07SEPT2016 Page 1 of 3

SPILL RESPONSE INCIDENT REPORT FORM

• SUBMIT THIS FORM WHEN:

1. ANY amount of hazardous substance has been released to the environment, e.g. soil, vegetation and/or any body of water; or

2. If 10 gallons or more of a hazardous or non-hazardous substance has been released anywhere.

• If the spill meets EITHER of these two criteria, contact the 63d RD Area Environmental Manager (AEM) for your area IMMEDIATELY (see phone #’s below). Note: Due to stringent state reporting times, spills must be reported no more than 12 hours from the time of discovery. When spill occurs:

1. Fill out this Incident Report Form.

2. Submit photos of the spill and the cleanup process.

3. Send form & photos to the AEM (call them for email address) and the Spill Response

Program Manager at Brendon.p.coye.ctr@mail.mil.

REFER TO YOUR FACILITY’S SITE SPECIFIC SPILL PLAN FOR ADDITIONAL SPILL RESPONSE PROCEDURES

-Examples of Hazardous Substances: fuel, oil, brake, transmission and hydraulic fluid, antifreeze, corrosives, flammables, combustibles, ammonia, anhydrous ammonia, mercury, cleaners, etc.

-Examples of Releases to the Environment: soil, water, conveyance to water (drain, drop inlet, catch-basin), etc.

* Certified Emergency Responder/On-Scene Responder

If applicable, indicate who you contacted at the 63d by checking the box(s) above.

Reporter’s Name: ______________________________________________________________ Position: _________________________________ Unit: ________________________________ Phone Number: ________________________________________________________________ Spill Location (Facility Name): _____________________________________________________ Address: ______________________________________________________________________

63d Area Environmental Manager (AEM) Phone #’s AEM Region Work # Mobile # Arkansas and Northeast Texas (501) 771-8928 (501) 442-1810 Oklahoma and Northwest Texas (405) 209-2804 (650) 468-3762 South Texas* (210) 381-9504 (650) 450-7463 Arizona, New Mexico, Nevada, West Texas - (650) 450-7438 Northern California - (650) 546-6529 Southern California - (760) 885-8824

Alternate 63d RD Environmental Division Emergency Contact #’s Environmental Chief (650) 526-9802 (650) 477-5946 Compliance Branch Chief* (650) 526-9408 (650) 636-3669 Spill Response Program Manager (408) 691-8154 (650) 526-9359 Hazardous Waste Program Manager* (580) 558-8103 (501) 442-1809

07SEPT2016 Page 2 of 3

INCIDENT DESCRIPTION

Spill Date: Time: ____ Material Spilled:

Quantity: __________________ Gallons Drums Other Units______________ Container Type: Tank Drum Other: __________________________________

DESCRIBE THE SPILL (CAUSE/SOURCE) AND WHERE IT WAS RELEASED TO:

WAS THE MATERIAL RELEASED TO: DID IT TRAVEL OFFSITE? Yes No Unsure

WATER

GROUND/SOIL

DRAIN

ASPHALT/PAVEMENT

OTHER

DESCRIBE CORRECTIVE ACTION TAKEN:

CHECK ALL THAT APPLY:

COVERED/BLOCKED STORM DRAIN

DEPLOYED BOOMS, PADS, ABSORBENT MATERIAL

REMOVED CONTAMINATED SOIL AFTER SAFETY CONSIDERATION TAKEN

CONSTRUCTED DIKE

OTHER

WAS THERE DAMAGE? : YES NO UNSURE

WERE THERE INJURIES/EVACUATIONS? : YES NO

07SEPT2016 Page 3 of 3

ADDITIONAL INFORMATION ABOUT THE INCIDENT:

Check Box2: Off

Check Box4: Off

Check Box5: Off

Check Box7: Off

Check Box46: Off

Check Box1: Off

Check Box3: Off

Reporters Name:

Position:

Unit:

Phone Number:

Spill Location Facility Name:

Address:

Check Box26: Off

Check Box29: Off

Check Box36: Off

Check Box37: Off

Check Box40: Off

Check Box41: Off

Check Box47: Off

Check Box49: Off

Check Box50: Off

Check Box51: Off

Check Box52: Off

Spill Date 1:

Spill Date 3:

Quantity:

Other Units:

Other:

Check Box21: Off

Check Box22: Off

Check Box23: Off

Text27:

Check Box28: Off

Check Box30: Off

Check Box31: Off

Check Box32: Off

Check Box33: Off

Check Box34: Off

Check Box35: Off

Text36:

Check Box42: Off

Check Box43: Off

Check Box44: Off

Check Box45: Off

Text47:

Text50:

Check Box20: Off

Check Box24: Off

Check Box25: Off

Text51:

REV. May 2009

PRICE REASONABLENESS DETERMINATION

(MEMORANDUM TO CONTRACT FILE)

PO/DO/CONTRACT NUMBER:

A. REASON WHY NO OTHER SOURCE IS ACCEPTABLE.

B. PRICE REASONABLENESS BASED ON (check one or more):

COMMERCIAL CATALOG/PUBLISHED PRICE LIST

NUMBER DATED PAGE NO.

ESTABLISHED MARKET PRICE:

MEANS OF VERIFICATION

COMPARISON WITH PRIOR PURCHASE OF SAME OR SIMILAR ITEM/SERVICE:

CONTRACTOR

ORDER/CONTRACT NO. DATE PURCHASED

QUANTITY UNIT UNIT PRICE

BASIS FOR DETERMINING PRIOR PRICE REASONABLE

ADEQUATE COMPETITION:_________________________________________________________________________

VALUE ANALYSIS BY BUYER/USER/TECHNICAL PERSONNEL: (Include review of technical data, evaluation of sample, etc.)

See attached statement.

OTHER: (Set forth specific reason, e.g. valid purchase request estimate, minimum order quantity, high priority and delivery, special packaging/marking.)

SIGNATURE OF BUYER/PURCHASING ASSISTANT/CONTRACTING OFFICER DATE

Print

New, Removed or Replaced Equipment Worksheet

8/26/20 Version 3

Submitters Info Site Details Name:

Phone:

E-mail:

Date:

New Equipment Details Install Date Room location Material Description Asset Number Model Number Serial Number Make Manufacture

N/A Quantity Capacity Barcode Refrigerant type

Removed Equipment Details Install Date Room

Material Description Asset Number Model Number Serial Number Make Manufacture

Quantity Capacity Barcode Refrigerant type

Warranty Duration Start Date End Date

Nameplate

Building Number Site Name

FACID

Warranty Company

WO# / Joc contract# / CSS ticket #

Is this part of a split system

Warranty Contact Info

Required Pictures (Please provide the name of the pictures for this equipment.)

Asset

Warranty Data

Scope of work/ Comments

Submitters Info: Self Explanatory. The person submitting the worksheet goes here.

Site Details: Facility ID, Site name, Building Number, and the work order or project number attached to the work being done.

New Equipment Details: If a whole piece of equipment is being installed, all information would go here.

• Install date: The date the equipment was physically installed.

• Room location: Self-explanatory. Captures the location of the equipment. It should be detailed enough for someone to easily locate the component. (ex. FL1-RM 137; FL2-RM 248; East Roof;

1st floor)

• Material Description: Captures the type of the equipment. (example: electric water heater, fuel-fired unit heater, chilled.)

• Asset Number: Leave blank; DPW Maximo/Builder specialist will assign.

• Model, Serial, Make, and Manufacture: Comes from equipment being installed.

• Quantity: Self-explanatory.

• Capacity: Captures the capacity of the equipment. In some cases the component type is a selection based on a round-up to the larger size. This field captures the actual capacity found in the field.

• Barcode: RSC# or identifier on the equipment or same number from replaced equipment.

• Refrigerant type: If applicable

Removed Equipment Details: If a whole piece of equipment is being removed, all information would go here.

• Install date: The date the equipment was originally installed (Usually found on the warranty tag or equipment’s data plate.)

fuel-fired unit heater)

• Asset Number: Comes from Maximo or PM work order check sheet.

• Model, Serial, Make, and Manufacture: Comes from equipment being removed.

selection based on a round-up to the larger size. This field captures the actual capacity found in the field.

• Barcode: RSC# or identifier on the equipment.

• Refrigerant type: if applicable

Replaced Equipment: If a whole piece of equipment is being replaced both new and removed will be filled out.

Split System: A two piece unit that, in most cases, has an outdoor condensing unit mated to an indoor control unit/fan coil and will sometimes have heat and cooling functions. If both are being replaced or removed then that WILL require 2 builder worksheets to be submitted and the box checked.

Scope of work / Comments: Provide a description with a concise summary statement of the work that was performed. This is also a good area to note a split system and has 2 builder worksheets.

Required Pictures: If there are pictures of the Asset here would be the area to put the .jpg name. The picture attachments would be able to be made in Maximo or on a page of the excel builder worksheet.

Warranty Data: This will be needing to be filled out if a piece of equipment has a warranty when installed. This being filled out will help the 88th maintain if a piece of equipment goes bad and needs replacing within that time frame.

Equipment Repair Worksheet

8/26/2020 Version 3

Site Details Name: FACID Phone: Site Name E-mail: Building Number

Date: WO#/Joc contract#/CSS ticket #

Equipment Details Install Date

Room

Material Description Asset Number Model Number Serial Number Make Manufacture

Quantity Capacity Barcode Refridgerant Type

QTY Manufacture Part or Model # Size

Warranty Duration Warranty Start Date Warranty End Date Warranty Company Warranty Contact Info

Warranty Data

Red Red -

Rate equipment (Please check the best rating per current observations)

Green + Green Green -

Amber + Red + Amber Amber -

Submitters Info

Scope of work/ Comments

Description Serial Number Parts list

Submitters Info: Self Explanatory. The person submitting the worksheet goes here.

Site Details: Facility ID, Site name, Building Number, and the work order or project number attached to the work being done.

Equipment Details: If a piece of equipment is being repaired, all information would go here.

• Install date: The date the equipment was physically installed.

fuel-fired unit heater.)

• Asset Number: Comes from Maximo or PM work order check sheet.

• Model, Serial, Make, and Manufacture: Comes from equipment being installed.

selection based rounded up larger size. This field captures the actual capacity found in the field.

• Barcode: RSC# or identifier on the equipment or same number from replaced equipment.

• Refrigerant type: If applicable

Scope of work / Comments: This will be where the description of what was done will go and any other comments the field team sees fit. This is a good area to note a split system and has 2 builder worksheets.

Rate Equipment: This is the condition index rate scale that the Field team will rate equipment when installed.

• GREEN + (100%) – The entire component is free of observable or known distresses.

• GREEN (95%) – No Component serviceability or reliability reduction.

• GREEN- (88%) - Slight to no serviceability or reliability reduction overall to the component.

• AMBER + (80%) – Component is degraded but adequate.

• AMBER (71%) – Component is definitely impaired.

• AMBER- (61%) - Component has significant serviceability or reliability reduction.

• RED + (50%) Component is severely degraded.

• RED (30%) – Component is barely able to perform

• RED – (10%) - Component is a complete loss.

Parts List: Any and all Parts that were taken out and replaced with new.

Warranty Data: This will be needing to be filled out if a piece of equipment has a warranty when installed. This being filled out will help the 88th maintain if a piece of equipment goes bad and needs replacing within that time frame.

New Removed or Replaced

CM Repair PM Inspect

Equipment Repair Worksheet.pdf

CM Repair PM Inspect

Name:

Phone:

Email:

Date:

Asset:

Nameplate:

WO Joc contract CSS ticket:

Facility ID:

Site Name:

Building Number:

New Install Date:

New Room location:

New Quantity:

New Material Description:

New Capacity:

New Model Number:

New Serial Number:

New Barcode:

New Make:

New Manufacture:

Refrigerant type:

Removed Quantity:

Removed Install Date:

Removed Room location:

Removed Material Description:

Removed Asset Number:

Removed Capacity:

Removed Model Number:

Removed Serial Number:

Removed Barcode:

Removed Make:

Removed Manufacture:

Removed Refrigerant type:

Split System?: Off

Scope Of Work & Comments:

Scope Of Work & Comments 1:

Scope Of Work & Comments 2:

Scope Of Work & Comments 3:

Scope Of Work & Comments 4:

Scope Of Work & Comments 5:

Warranty Company 2:

Warranty Contact Information:

Warranty Contact Information 2:

Warranty Duration:

Warranty Duration 2:

Warranty Start Date:

Warranty Start Date 2:

Warranty's End Date:

Name1:

Phone1:

Site Name 1:

Email 1:

Building Number 1:

Date 1:

WOJoc contractCSS ticket 1:

Install Date:

Room location:

Material Description:

Asset Number:

Model Number:

Serial Number:

Make:

Manufacture:

Quantity:

Capacity:

Barcode:

Refridgerant Type:

DescriptionRow1:

ManufactureRow1_2:

Part or Model Row1:

Serial NumberRow1_2:

SizeRow1:

DescriptionRow2:

ManufactureRow2:

Part or Model Row2:

Serial NumberRow2:

SizeRow2:

DescriptionRow3:

ManufactureRow3:

Part or Model Row3:

Serial NumberRow3:

SizeRow3:

DescriptionRow4:

ManufactureRow4:

Part or Model Row4:

Serial NumberRow4:

SizeRow4:

DescriptionRow5:

ManufactureRow5:

Part or Model Row5:

Serial NumberRow5:

SizeRow5:

DescriptionRow6:

ManufactureRow6:

Part or Model Row6:

Serial NumberRow6:

SizeRow6:

DescriptionRow7:

ManufactureRow7:

Part or Model Row7:

Serial NumberRow7:

SizeRow7:

DescriptionRow8:

ManufactureRow8:

Part or Model Row8:

Serial NumberRow8:

SizeRow8:

DescriptionRow9:

ManufactureRow9:

Part or Model Row9:

Serial NumberRow9:

SizeRow9:

DescriptionRow10:

ManufactureRow10:

Part or Model Row10:

Serial NumberRow10:

SizeRow10:

Warranty Contact InfoRow1:

Warranty DurationRow1:

Warranty Start DateRow1:

Warranty End DateRow1:

Warranty Contact InfoRow2:

Warranty DurationRow2:

Warranty Start DateRow2:

Warranty End DateRow2:

Green +: Off

Green: Off

Green -: Off

Amber +: Off

Amber: Off

Amber -: Off

Red +: Off

Red: Off

Red -: Off

Facility ID 1:

Scope of Work / Comments:

Scope of Work / Comments 1:

Scope of Work / Comments 2:

Scope of Work / Comments 3:

Scope of Work / Comments 4:

Scope of Work / Comments 5:

Scope of Work / Comments 6:

Quantity 1:

Quantity 2:

Quantity 3:

Quantity 4:

Quantity 5:

Quantity 6:

Quantity 7:

Quantity 8:

Quantity 9:

Quantity 10:

Warranty Company:

warranty company 2: