Attachments.pdf

Attachment 1

(Put on Company Letterhead)

QUALITY CONTROL PLAN

W911WN-20-D-X3XXX

Building and Grounds Maintenance Service East Branch Clarion River Lake

Wilcox, Pennsylvania

Brief statement describing your company’s management philosophy relative to its commitment to quality.

1. Describe inspection process for each section of the contract.

2. List names of inspectors.

3. Describe process to identify deficiencies in quality of services performed before the level of performance is unacceptable.

4. Describe process for retaining records of inspections and corrective actions taken.

5. Accident Prevention:

a. Policy Statement for accident prevention signed by the Contractor (program and enforcement)

b. Emergency phone numbers

c. Equipment inspections

d. Safety training

e. Personal protective equipment required

Signature of contractor Date: _______________

Approved by: Date: ________________

COR

ACCIDENT PREVENTION PLAN

Building and Grounds Maintenance Services East Branch Clarion River Lake

Contract Number Contractor Name

1. SIGNATURE SHEET.

This Accident Prevention Plan was

Prepared By:

Name Title of corporate safety staff person

Approved By:

Name President

2. BACKGROUND INFORMATION

a. Contractor: Name Address City, State Zip

b. Contract Number W911WN-20-D-3###

c. Project Name: East Branch Clarion River Lake

d. Project Description: Building and Grounds Maintenance Service

e. Name of Company’s recent accident history is included as Attachment #__ to this Accident Prevention Plan. Information included includes EMR, OSHA 200 Forms and corporate safety trend analyses.

f. The Major definable features of work are: ______________________________. An Activity Hazard Analysis (AHA) will be prepared for each Major Definable Feature of Work. AHAs will be prepared in accordance with the format shown on page 4 of EM 385-1-1 and will be presented

Attachment 2 and discussed at the Preparatory Phase Inspection for the applicable feature of work.

3. STATEMENT OF SAFETY AND HEALTH POLICY

Enter statement which describes the company‘s commitment to safety.

4. RESPONSIBILITIES AND LINES OF AUTHORITIES

a. Name - Describe responsibility and accountability of personnel responsible for safety at corporate level.

b. Name - Describe responsibility and accountability of personnel responsible for safety at project level.

c. Lines of authority - Describe lines of authority (as related to safety) for this project.

5. SUBCONTRACTORS AND SUPPLIERS.

a. The following subcontractors will be working on this project:

1. List

b. The CQC System Manger (if someone else, identify) will be responsible for controlling and coordinating subcontractors and suppliers.

c. All subcontractors and suppliers performing work on site will be expected to conform to the requirements of this Accident Prevention Plan and to the requirements of EM 385-1-1.

6. TRAINING.

a. Each employee will receive a safety indoctrination consisting of a thorough review of applicable AHA’s.

b. The following is a list of mandatory training and certifications which are applicable to this project:

1. Vehicle Operator

2. Personal Protective Equipment)

3. Other

c. The following identifies requirements for periodic retraining or recertification relating to item b above.

1. List

d. The following individuals shall be trained in the contents of the Emergency Response Plan discussed in Section 12 of this Accident Prevention Plan:

1. List

e. Weekly toolbox safety meeting will be conducted at TIME every ENTER DAY OF WEEK.

Each on site worker will be required to attend. Attendance will be documented. Name will be responsible for conducting these meetings.

7. SAFETY AND HEALTH INSPECTIONS.

a. Name will conduct site safety inspections on a daily basis. Any noted deficiencies will be identified on that day’s CQC Report. Deficiencies will be tracked using the table included as Attachment # __ to this Accident Prevention Plan.

b. The following external inspections/certifications are required for this project:

List or enter “None Required”.

8. SAFETY AND HEALTH EXPECTATIONS, INCENTIVE PROGRAMS, AND

COMPLIANCE

a. Provide a statement or statements describing the company's written safety program goals, objectives, and accident experience goals for this contract.

b. Provide a brief description of the company's safety incentive programs (if any). If none, so state.

c. Provide a discussion of the company’s policies and procedures regarding noncompliance with safety requirements (to include disciplinary actions for violation of safety requirements).

d. Provide written company procedures for holding managers and supervisors accountable for safety.

9. ACCIDENT REPORTING

a. Name will submit Monthly Manhour Exposure Reports to the Contracting Officer no later than the 5th work day of each month. The report encompasses on-site work including all hourly and salaried employees. The report will include all subcontractors working on this project.

b. Name will complete the report and submit it to the Contracting Officer within five (5) workdays.

c. Name will immediately notify the Contracting Officer and District Safety Officer of any incidents involving a fatality or permanent total disability, accidents in which three or more persons are hospitalized, accidents that result in property damage in excess of $100,000 or any accident regardless of the consequences, if it is suspected that it will result in unfavorable criticism of the Corps of Engineers..

10. MEDICAL SUPPORT

a. A list of emergency telephone numbers and a map of directions to the nearest hospital(s) is included in the Emergency Response Plan section of this Accident Prevention Plan.

b. First aid kits will be maintained on site as required in Section 3 of EM 385-1-1.

c. At least two employees on each shift will be qualified to administer first aid and CPR.

Individuals who are required to work alone in remote areas shall be trained in first aid. The following employees are certified in First Aid and CPR and a copy of their current certificates are included as Attachment # __ to this Accident Prevention Plan:

1. List

11. PERSONAL PROTECTIVE EQUIPMENT.

a. Outline procedures (who, when, how) for conducting hazard assessments and written certifications for use of personal protective equipment.

12. PLANS (PROGRAMS, PROCEDURES) REQUIRED BY THE SAFETY MANUAL (as applicable)

a. Hazard Communication (HAZCOM) Program (01.B.04)

Included as Attachment # __ to this Accident Prevention Plan is a written hazard communication program addressing as a minimum, the following: training (to include potential safety and health effects from exposure), labeling, current inventory of hazardous chemicals on site, and the location and use of Material Safety Data Sheets (MSDSs).

b. Emergency Response Plans (01.E.01, 01.E.05, 06.A.02, 19.A.04, 09.K.01 and 09.K.02)

An Emergency Response Plan is included as Attachment # __ to this Accident Prevention Plan. This Emergency Response Plan includes:

An Emergency Response Plan to ensure employee safety in case of fire or other emergency.

Emergency telephone numbers and reporting instructions for ambulance, physician, hospital, fire, and police. Also included is a map of directions to the nearest hospital(s). This list and map shall be conspicuously posted at the work site.

c. Respiratory Protection Plan (05.E.01)

Name of Company‘s Respiratory Protection Plan is included as Attachment # __ to this Accident Prevention Plan.

d. Health Hazard Control Program (06.A.02)

Activity Hazard Analyses (AHA’s) shall consider all substances, agents and environments that present a hazard and will recommend hazard control measures. Engineering and administrative controls shall be used to control hazards. In cases where engineering or administrative controls are not feasible, PPE may be used. The AHA shall serve as certification that a hazard assessment has been conducted.

e. Plan for Prevention of Alcohol and Drug Abuse (Defense Federal Acquisition Regulation Supplement Subpart 252.223-7004, Drug-Free Work Force)

Name of Company‘s plan for prevention of Alcohol and Drug Abuse is included as Attachment # __ to the Accident Prevention Plan. This plan meets the minimum requirements of

DFAR 252.223-7004.

13. Detailed site specific hazards and controls will be provided in the activity hazard analysis (AHA) for each phase of the operation (each Major Definable Feature of Work as defined by the Contractor Quality Control Plan). The AHA’s will provide information on how the requirements of major sections of EM 385-1-1 will be met. Particular attention shall be paid to excavations, scaffolding, medical and first aid requirements, sanitation, personal protective equipment, fire prevention, machinery and mechanized equipment, electrical safety, public safety requirements, and chemical, physical agent, and biological occupational exposure prevention requirements.

AHA’s will be prepared utilizing the format shown on page 4 of EM 385-1-1.

Attachments Attachment # - Accident History Attachment # - Safety Deficiency Tracking Table Attachment # - Emergency Response Plan Attachment # - First Aid and CPR certificates Attachment # - Hazard Communication (HAZCOM) Program Attachment # - Emergency Response Plan Attachment # - Plan for Prevention of Alcohol and Drug Abuse

Risk Assessment Code (RAC):

S e v e r i t y

Project: Job:

E = Extremely High Risk

M = Moderate Risk L = Low Risk

Recommended Protective Clothing & Equipment:

H = High Risk

Prepared By: Reviewed By:

Date Prepared (dd-mmm-yy):

ACTIVITY HAZARDS ANALYSIS

JOB STEPS

Catastrophic

Critical

Marginal

Negligible

ACTIONS TO ELIMINATE OR

MINIMIZE HAZARDS

HAZARDS

E

H

M L

E

H

M

L

(PARA REF)

H

H

M

H

EM 385-1-1

E

L

P r o b a b i l i t y Frequent Likely Occasional UnlikelySeldom

M

L

M

L

L

L

CELRL Form 1259, November 2001 Previous Versions are Obsolete and Should Not Be Used

Attachment 3

Page 2 of 5ACTIVITY HAZARDS ANALYSIS Date Prepared (mm-dd-yyyy):

Project: Job:

JOB STEPS HAZARDS

ACTIONS TO ELIMINATE OR EM 385-1-1

MINIMIZE HAZARDS (PARA REF)

Page 3 of 5ACTIVITY HAZARDS ANALYSIS

ACTIONS TO ELIMINATE OR EM 385-1-1

MINIMIZE HAZARDS (PARA REF)

Project: Job:

JOB STEPS HAZARDS

JOB STEPS HAZARDS

ACTIONS TO ELIMINATE OR EM 385-1-1

MINIMIZE HAZARDS (PARA REF)

Date Prepared (mm-dd-yyyy):

Project: Job:

ACTIVITY HAZARDS ANALYSIS

Page 5 of 5ACTIVITY HAZARDS ANALYSIS

Project: Job:

JOB STEPS HAZARDS

ACTIONS TO ELIMINATE OR EM 385-1-1

MINIMIZE HAZARDS (PARA REF)

Full name

Social Security Number

Date of Birth

Place of Birth

Please direct any questions to the Stephen Davidson, 412-395-7504 or stephen.davidson@usace.army.mil.

NOTE: These background checks can take up to 14 days for U.S. citizens and 30 days for Foreign nationals.

The District retains the right to deny any contractor and subcontractor employee from working on one of its contracts based on final background investigation results.

Attachment 4

Fax Cover Sheet

TO: Stephen Davidson FAX: 412.395.7173

FROM: PHONE: ____________________ _______

_________________________________________ E-MAIL: ______________@______________

CONTRACT #: W911WN___________________

PROJECT: ____________________________________________

USACE Contracting Officer’s Representative (COR) or Point of Contact (POC): ____________________________

I.A.W. AT/OPSEC 2 requirements, to protect their privacy, please use this coversheet to fax your employees/subcontractors Personally Identifiable Information requested below.

The contractor and all associated subcontractors' employees shall comply with applicable installation, facility, and area commander installation and facility access and local security policies and procedures (provided by the Government Representative).

The contractor shall also provide all information required for background checks to meet installation access requirements to be accomplished by the installation the USACE Security Office.

The contractor workforce must comply with all personal identity verification requirements as directed by DoD, HQDA, and/or local policy. In addition to the changes otherwise authorized by the Changes clause of this contract, should the Force Protection Condition (FPCON) at any individual facility or installation change, the Government may require changes in contractor security matters or processes.

The contractor must submit:

5.

d. CONTRACTOR'S NAME

SIDE SWIPE

BROADSIDE

OTHER (Specify)

e. BODY PART AFFECTED

REAR END

BACKING

HEAD ON

ROLL OVER

d. ESTIMATED DAYS

RESTRICTED DUTY

b. ESTIMATED

DAYS LOST

c. ESTIMATED

DAYS HOSPIT-

ALIZED

b. TYPE OF CONSTRUCTION EQUIPMENT

SUPERFUND

IRP

b. TYPE OF COLLISION/MISHAP

a. ACTIVITY AT TIME OF ACCIDENT

g. HAZARDOUS/TOXIC WASTE

ACTIVITY

(For Safety Staff only)

REPORT NO. EROC

CODE UNITED STATES ARMY CORPS OF ENGINEERS

ACCIDENT INVESTIGATION REPORT

REQUIREMENT

CONTROL SYMBOL:

CEEC-S-8(R2)

PERSONNEL CLASSIFICATION

GOVERNMENT

INJURY/ILLNESS/FATAL PROPERTY DAMAGE MOTOR VEHICLE INVOLVED DIVING

a. Name (Last, First, MI) b. AGE c. SEX d. SOCIAL SECURITY NUMBER e. GRADE

f. JOB SERIES/TITLE g. DUTY STATUS AT TIME OF ACCIDENT h. EMPLOYMENT STATUS AT TIME OF ACCIDENT

a. DATE OF ACCIDENT (month/day/year)

b. TIME OF ACCIDENT (Military time)

e. CONTRACT NUMBER f. TYPE OF CONTRACT

c. EXACT LOCATION OF ACCIDENT

a. CONSTRUCTION ACTIVITY

a. SEVERITY OF ILLNESS/INJURY

g. TYPE AND SOURCE OF INJURY/ILLNESS

f. NATURE OF ILLNESS/INJURY

a. TYPE OF VEHICLE

a. NAME OF ITEM b. OWNERSHIP c. $ AMOUNT OF DAMAGE

(1)

(2)

(3)

a. TYPE OF VESSEL/FLOATING PLANT

b. PERSONAL FLOATATION DEVICE USED?

b. TYPE OF COLLISION c. SEAT BELTS USED NOT USED NOT AVAILABLE

(1) FRONT SEAT

(2) REAR SEAT

10. ACCIDENT DESCRIPTION (Use additional paper, if necessary)

8. PROPERTY/MATERIAL INVOLVED

9. VESSEL/FLOATING PLANT ACCIDENT (Fill in line and correspondence code number in box from list - see help menu)

7. MOTOR VEHICLE ACCIDENT

INJURY/ILLNESS INFORMATION (Include name on line and corresponding code number in box for items e, f & g - see help menu)

4. CONSTRUCTION ACTIVITIES ONLY (Fill in line and corresponding code number in box from list - see help menu)

3. GENERAL INFORMATION

2. PERSONAL DATA

1. ACCIDENT CLASSIFICATION

6. PUBLIC FATALITY (Fill in line and correspondence code number in box - see help menu)

CIVILIAN MILITARY

CONTRACTOR

FIRE

INVOLVED OTHER

FIRE

INVOLVED OTHER

OTHERFATAL

MALE FEMALE

ON DUTY

OFF DUTY

TDY

ARMY ACTIVE

PERMANENT

TEMPORARY

OTHER (Specify)

ARMY RESERVE

FOREIGN NATIONAL

STUDENT

VOLUNTEER

SEASONAL

CONSTRUCTION

A/E

OTHER (Specify)

SERVICE

DREDGE

DERP

OTHER (Specify)

(1) PRIME:

(2) SUBCONTRACTOR:

(CODE) (CODE)

(CODE)

(CODE)

(CODE)

(CODE)

(CODE)

(CODE)

(CODE) (CODE)

(CODE)

CIVIL WORKS

OTHER (Specify)

MILITARY

PRIMARY

SECONDARY TYPE

SOURCE

YES N/ANO

AUTOMOBILE

OTHER (Specify)

PICKUP/VAN

TRUCK

ENG FORM 3394, MAR 99 EDITION OF SEP 89 IS OBSOLETE. Page 1 of 4 pages (Proponent: CESO ) hrs

(For Use of this Form See Help Menu and USACE Suppl to AR 385-40)

PUBLIC

Version 2

Attachment 5 a.

a.

a.

b. TYPE OF TRAINING.a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK?

b. WAS A WRITTEN JOB/ACTIVITY HAZARD ANALYSIS COMPLETED

FOR TASK BEING PERFORMED AT TIME OF ACCIDENT?

a. (CONTINUED)a. (Explain YES answers in item 13)

CAUSAL FACTOR(S) (Read Instruction Before Completing)11.

TRAINING12.

FULLY EXPLAIN WHAT ALLOWED OR CAUSED THE ACCIDENT; INCLUDE DIRECT AND INDIRECT CAUSES (See instruction for definition of direct and indirect causes.) (Use additional paper, if necessary)

13.

ACTION(S) TAKEN, ANTICIPATED OR RECOMMENDED TO ELIMINATE CAUSE(S).14.

DATES FOR ACTIONS IDENTIFIED IN BLOCK 14.15.

MANAGEMENT REVIEW (1st)16.

MANAGEMENT REVIEW (2nd - Chief Operations, Construction, Engineering, etc.)17.

SAFETY AND OCCUPATIONAL HEALTH OFFICE REVIEW18.

COMMAND APPROVAL19.

c. DATE OF MOST RECENT FORMAL TRAINING.

a. DIRECT CAUSE

b. INDIRECT CAUSE(S)

DESCRIBE FULLY:

c. SIGNATURE AND TITLE OF SUPERVISOR COMPLETING REPORT

CORPS

CONTRACTOR

d. DATE (Mo/Da/Yr) e. ORGANIZATION IDENTIFIER (Div, Br, Sect) f. OFFICE SYMBOL

SIGNATURE TITLE DATE

COMMENTS

DATE

DATE

DATECOMMANDER SIGNATURE

TITLE

TITLE

SIGNATURE

SIGNATURE

a. BEGINNING (Month/Day/Year) b. ANTICIPATED COMPLETION (Month/Day/Year)

DESIGN: Was design of facility, workplace or equipment a factor?

INSPECTION/MAINTENANCE: Were inspection & mainten-ance procedures a factor?

PERSON'S PHYSICAL CONDITION: In your opinion, was the physical condition of the person a factor?

OPERATING PROCEDURES: Were operating procedures a factor?

JOB PRACTICES: Were any job safety/health practices not followed when the accident occurred?

HUMAN FACTORS: Did any human factors such as, size or strength of person, etc., contribute to accident?

ENVIRONMENTAL FACTORS: Did heat, cold, dust, sun, glare, etc., contribute to the accident?

OFFICE FACTORS: Did office setting such as, lifting office furniture, carrying, stooping, etc., contribute to the accident?

SUPPORT FACTORS: Were inappropriate tools/resources provided to properly perform the activity/task?

PERSONAL PROTECTIVE EQUIPMENT: Did the improper selection, use or maintenance of personal protective equipment contribute to the accident?

DRUGS/ALCOHOL: In your opinion, was drugs or alcohol a factor to the accident

CHEMICAL AND PHYSICAL AGENT FACTORS: Did exposure to chemical agents, such as dust, fumes, mists, vapors or physical agents, such as, noise, radiation, etc., contribute to accident?

CONCUR b. NON CONCUR c. COMMENTS

CONCUR b. NON CONCUR c. COMMENTS

CONCUR b. NON CONCUR c. ADDITIONAL ACTIONS/COMMENTS

Page 2 of 4 pages

YES (If yes, attach a copy.) NO

NOYES ON JOBCLASSROOM (Month) (Day) (Year)

YES NO YES NO

*U.S. GOVERNMENT PRINTING OFFICE: 1993-0-791-757

ACCIDENT DESCRIPTION (Continuation)

DIRECT CAUSE (Continuation)

10.

13a.

Page 3 of 4 pages

INDIRECT CAUSES (Continuation)

ACTION(S) TAKEN, ANTICIPATED, OR RECOMMENDED TO ELIMINATE CAUSE(S) (Continuation)

13b.

14.

Page 4 of 4 pages

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO (Contractor and Manager's Name) 4. FROM (Name of QAE)

5. DATES (YYYYMMDD)

a. PREPARED b. RETURNED BY CONTRACTOR c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF CONTRACTING OFFICER

8a. TO (Contracting Officer) b. FROM (Contractor)

9. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. (Cite applicable Q.C.

program procedures or new Q.C. procedures. Attach continuation sheet(s) if necessary.)

10. SIGNATURE OF CONTRACTOR REPRESENTATIVE b. DATE (YYYYMMDD)

11. GOVERNMENT EVALUATION (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary)

12. GOVERNMENT ACTIONS (Reduced payment, cure notice, show cause, other)

13. CLOSE OUT

NAME

(1)

TITLE

(2)

SIGNATURE

(3)

DATE (YYYYMMDD)

(4)

a. CONTRACTOR

NOTIFIED

b. QAE

c. ACO

DD FORM 2772, SEP 1998 (EG) REPLACES MT FORM 352-R, WHICH IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Sep 98

ATTACHMENT 6

PESTICIDE APPLICATION RECORD 11. START DATE (YYYYMMDD)

2 INSTALLATION

3 SITE TREATED

4. PEST TREATED

5. PURPOSE

SECTION I - CONDITIONS DURING TREATMENT

1. AIR TEMPERATURE (Fahrenheit Degrees) 12. WATER TEMPERATURE (Fahrenheit Degrees if applicable)

3. OVERCAST (Percentage %) 14. WIND DIRECTION (N, NE, E, SE, S, SW, W or NW) 15. WIND VELOCITY (mph)

SECTION II - PESTICIDE RECORD

1. COMMON NAME

2. ACTIVE INGREDIENT AND PERCENTAGE%

3. MANUFACTURER 14. REGISTRATION NUMBER

5. REGISTRERED USE

6. MATERIAL SAFETY DATA SHEETS (MSDS) AVAILABLE 0 YES ONO

7. PERSONAL PROTECTION EQUIPMENT DEVICE WORN DURING APPLICATION O MASK (Dust Unfiltered)□ BREATHING APPARATUS

0 MASK (Filtered) 0 EYEWEAR 0 GLOVES O BOOTS 0 HOOD O PROTECTIVE SUIT 0 TREATED AREA ENCLOSED

0 TREATED AREA OPEN (Ventilated) 0 NONE REQUIRED OR WORN PER MSDS DATA 0 OTHER SAFETY REQUIREMENTS

8. MIXTURE OR FORM APPLIED (e.g., 20 to 1, Spray, paste, poured, fumigation or Solid)

9. APPLICATION RA TE 110. APPLICATION METHOD

11. SPECIAL PRECAUTIONS TAKEN (if none so state)

12. NUMBER OF PERSONNEL USED IN APPLICATION (list other personnel in remarks below)

13. OTHER EQUIPMENT USED NOT PREVIOUSLY LISTED

14. ACCUMULATIVE TREATMENT (Quantity of Pesticide applied to a 15. COOPERATING AGENCIES given area during the calendar year)

a. UNITS TREATED b. QUANTITY USED

(1) PREVIOUS (1) PREVIOUS

(2) PRESENT (2) PRESENT

(3) TOTAL (3) TOTAL

16. REMARKS

SECTION 111- CERTIFIED APPLICATOR'S SIG�ATURE CERTIFICATION

I HEREBY CERTIFY THAT THIS INFORMATION IS A TRUE AND CORRECT RECORD OF THE PESTICIDE APPLICATION.

1. OTHER DOCUMENTATION ATTACHED

0 YES 0 NO

CELRI FORM 1031, APR 2010

2a. DATE (YYYYMMDD) b. SIGNATURE (Certified Applicator)

PREVIOUS EDITIONS ARE OBSOLETE. VERSION 11

Attachment 7

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ATTACHMENT 7

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