Discrepancy_and_Hazard_Report_Forms.pdf

ATTACHMENT 1

CONTRACT DISCREPANCY REPORT

Instructions: QAP fills in blocks 1, 3, 4, 5 (prepared), and 6. Contractor fills in blocks 9 and 10.

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contractor and Managers Name) 4. FROM: (Name of QAE)

5. DATES

PREPARED RETURNED BY CONTRACTOR ACTION COMPLETE

6. DISCREPANCY OR PROBLEM: (Describe in detail: include applicable SOW/Contract references: attach continuation sheet if necessary.)

7. SIGNATURE OF CONTRACTING OFFICER

8. TO: (Contracting Officer) FROM: (Contractor)

9. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE: ATTACH CONTINUATION SHEET IF NECESSARY. (Cite applicable Q.C. program procedures or new Q.C. procedures.)

10. SIGNATURE OF CONTRACTOR REPRESENTATIVE

DATE

11. GOVERNMENT EVALUATION (Acceptance, partial acceptance, rejection; attach continuation sheet if necessary.)

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

CLOSE OUT

NAME-TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

QAE

ACO

ATTACHMENT 2

Activity Hazard Analysis (AHA)

Activity/Work Task: Overall Risk Assessment Code (RAC) (Use highest code)

Project Location: Risk Assessment Code (RAC) Matrix Contract Number:

Severity Probability

Date Prepared: Frequent Likely Occasional Seldom Unlikely Prepared by (Name/Title): Catastrophic E E H H M

Critical E H H M L Reviewed by (Name/Title): Marginal H M M L L

Negligible M L L L L Notes: (Field Notes, Review Comments, etc.)

Step 1: Review each “Hazard” with identified safety “Controls” and determine RAC (See above)

“Probability” is the likelihood to cause an incident, near miss, or accident and identified as: Frequent, Likely, Occasional, Seldom or Unlikely.

RAC Chart

“Severity” is the outcome/degree if an incident, near miss, or accident did occur and identified as: Catastrophic, Critical, Marginal, or Negligible

E = Extremely High Risk

H = High Risk Step 2: Identify the RAC (Probability/Severity) as E, H, M, or L for each “Hazard” on AHA. Annotate the overall highest RAC at the top of AHA.

M = Moderate Risk

L = Low Risk

Job Steps Hazards Controls RAC

Equipment to be Used Training Inspection Requirements