A.1.9_Specifications_15R0008.pdf

PDF 4 MB Posted Aug 6, 2015

Attached to: Treated Water Plant Rehab, Ozark Powerhouse, Franklin County, AR
Solicitation number: W9127S-15-R-0008
Issued by: Department of the Army Corps of Engineers Engineering District Little Rock

About this file

From the source

Specifications

View the file

Other files

File	Type	Posted
A.2.11.3.1_Amendment_0001_15R0008.pdf	PDF	Aug 25, 2015
A.1.9_Plans_15R0008.pdf	PDF	Aug 6, 2015
A.2.11.3_Solicitation_15R0008.pdf	PDF	Aug 6, 2015

On GovTribe

Work with this file

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

US Army Corps of Engineers Little Rock District SPECIFICATIONS

TREATED WATER PLANT REHAB

OZARK POWERHOUSE

OZARK LOCK AND DAM

McCLELLAN-KERR ARKANSAS RIVER

NAVIGATION SYSTEM

FRANKLIN COUNTY, ARKANSAS

PN102707

JUNE 2015

SOLICITATION NO. W9127S-15-R-0008

PROJECT TABLE OF CONTENTS

DIVISION 01 - GENERAL REQUIREMENTS

01 00 50 FORMS AND ATTACHMENTS

01 11 00 SUMMARY OF WORK

01 14 00.00 46 WORK RESTRICTIONS (SWL)

01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS

01 22 00.00 10 MEASUREMENT AND PAYMENT

01 32 16.01 CONSTRUCTION PROGRESS DOCUMENTATION

01 33 00 SUBMITTAL PROCEDURES

01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

01 42 00 SOURCES FOR REFERENCE PUBLICATIONS

01 45 00.00 10 QUALITY CONTROL

01 45 00.10 10 QUALITY CONTROL SYSTEM (QCS)

01 57 20.00 10 ENVIRONMENTAL PROTECTION

01 78 00 CLOSEOUT SUBMITTALS

01 78 23 OPERATION AND MAINTENANCE DATA

DIVISION 02 - EXISTING CONDITIONS

02 41 00 DEMOLITION

DIVISION 05 - METALS

05 50 13 MISCELLANEOUS METAL FABRICATIONS

DIVISION 13 - SPECIAL CONSTRUCTION

13 48 00.00 10 SEISMIC PROTECTION FOR MECHANICAL EQUIPMENT

DIVISION 22 - PLUMBING

22 00 00 PLUMBING, GENERAL PURPOSE

DIVISION 23 - HEATING, VENTILATING, AND AIR CONDITIONING

23 07 00 THERMAL INSULATION FOR MECHANICAL SYSTEMS

DIVISION 26 - ELECTRICAL

26 05 00.00 40 COMMON WORK RESULTS FOR ELECTRICAL

-- End of Project Table of Contents --

PROJECT TABLE OF CONTENTS Page 1

PN102707

Ozark Powerhouse, Ozark Lock and Dam McClellan-Kerr Arkansas River Navigation System Franklin County, Arkansas Solicitation No. W9127S-15-R-0008

THIS PAGE INTENTIONALLY LEFT BLANK

Ozark Powerhouse, Ozark Lock and Dam

SECTION 01 00 50

FORMS AND ATTACHMENTS

PART 1 GENERAL

Listed below, and attached at the end of this section, are forms and attachments referred to in to other parts of the technical specifications.

1.1 SUBMITTAL REGISTER

See Section 01 33 00 SUBMITTAL PROCEDURES

1.2 TRANSMITTAL FORM (ENG FORM 4025-R)

See Section 01 33 00 SUBMITTAL PROCEDURES

1.3 ACTIVITY HAZARD ANALYSIS (AHA)

See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

1.4 ACCIDENT INVESTIGATION REPORT (ENG FORM 3394)

See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

1.5 SWL FORM 463

1.6 OSHA FORM 300 & 301

See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

1.7 RMS-QCS MONTHLY INJURIES-ILLNESSES & EXPOSURE

See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

1.8 SAFETY PERFORMANCE SIGN

See Section 01 14 00.00 46 WORK RESTRICTIONS

1.9 PROJECT IDENTIFICATION SIGN

See Section 01 14 00.00 46 WORK RESTRICTIONS

1.10 PERSONNEL SECURITY INVESTIGATION GUIDE

See Section 01 14 00.00 46 WORK RESTRICTIONS

1.11 USACE-LITTLE ROCK DISTRICT NATIONAL BACKGROUND SCREENING

CONSENT/RELEASE FORM (SSCI-2013)

See Section 01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS

1.12 OPTIONAL FORM 306

See Section 01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS

SECTION 01 00 50 Page 1

PN102707

Ozark Powerhouse, Ozark Lock and Dam

1.13 SWL Form 487 USACE-SWL CONTRACTOR REQUIRED INFORMATION FORM

See Section 01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS

PART 2 PRODUCTS

Not Used.

PART 3 EXECUTION

Not Used

-- End of Section --

SECTION 01 00 50 Page 2

PN102707

Ozark Powerhouse, Ozark Lock and Dam

S U

B M

R M

,J an

P R

E V

S E

B S

A G

O F

A G

E S

Tr ea te d

W at er P la nt

R eh ab

S D

-0

P re co ns tru ct io n

S ub m itt al s

G S ub m itt al

R eg is te r

D -0

P re co ns tru ct io n S ub m itt al s 1.

A cc id en t P re ve nt io n

P la n (A

P P

A ct iv ity

H az ar d

A na ly si s (A

H A

C ra ne O pe ra to rs

S D

-0

Te st

R ep or ts

N ot ifi ca tio ns a nd

R ep or ts

.2 G

A cc id en t R ep or ts

S D

-0

C er tif ic at es

H ot w or k pe rm it

Li ce ns e

C er tif ic at es

D -0

P re co ns tru ct io n S ub m itt al s 3.

C on tra ct or Q ua lit y C on tro l ( C

Q C

P la n

D -0

P re co ns tru ct io n S ub m itt al s 1.

E nv iro nm en ta l P ro te ct io n

P la n

D -0

P ro du ct D at a

A s-

B ui lt R ec or d of

E qu ip m en t an d

M at er ia ls 1.

S pa re P ar ts

D at a S

D -0

M an uf ac tu re r’s

In st ru ct io ns

P re ve nt at iv e M ai nt en an ce 1.

C on di tio n

M on ito rin g (P re di ct iv e Te st in

g) 1.

In sp ec tio n

R C

O N

C T

N O

E A

N D

L O

C A

N C

O N

C O

A C

C H

E D

D A

C O

A C

N A

P P

R O

G A

O R

A C T I V I T Y N O

T R A N S M I T T A L N O

S P E C S E C T

D E

S C

M S

U B

P A R A G R A P H

C L A S S I F I C A T I O N

G O V T O R A / E R E V W R S

U B

A P

P R

O V

A L

N E

E D

B Y

M A

N E

E D

B Y

A C T I O N C O D E

D A

F A

O N

D A

W D

P P

R A

D A

C D

M C

O N

D A

W D

R R

E V

E R

D A

C D

M O

E V

E R

A C T I O N C O D E

D A

F A

O N

M A

C O

D A

C D

A P

P R

A U

E M

A R

K S

(f) (g

(i)

(j) (k

(l)

PN102707

Ozark Powerhouse, Ozark Lock and Dam

B M

R M

,J an

P R

E V

S E

B S

A G

O F

A G

E S

Tr ea te d

W at er P la nt

R eh ab

In st ru ct io ns

S D

-1

O pe ra tio n an d M ai nt en an ce D at a

G O pe ra tio n an d

M ai nt en an ce

M an ua ls

S D

-1

C lo se ou t S ub m itt al s

R ec or d

D ra w in gs

D -0

P re co ns tru ct io n S ub m itt al s 1.

E xi st in g C on di tio ns

S D

-0

C er tif ic at es

D em ol iti on P la n

G N ot ifi ca tio n S

D -1

C lo se ou t S ub m itt al s R ec ei pt s

S D

-0

S ho p D ra w in gs

G su pp or ts a nd b ra ck et s

D -0

S ho p

D ra w in gs 3.

C ou pl in g an d

B ra ci ng

Fl ex ib le

C ou pl in gs o r J oi nt s

E qu ip m en t R eq ui re m en ts

C on tra ct or D es ig ne d

B ra ci ng

S D

-0

P ro du ct

D at a 3.

C ou pl in g an d

B ra ci ng

E qu ip m en t R eq ui re m en ts

C on tra ct or

D es ig ne d B ra ci ng

D -0

S ho p

D ra w in gs

R C

O N

C T

N O

E A

N D

L O

C A

N C

O N

C O

A C

C H

E D

D A

C O

A C

N A

P P

R O

G A

O R

A C T I V I T Y N O

T R A N S M I T T A L N O

S P E C S E C T

D E

S C

M S

U B

P A R A G R A P H

C L A S S I F I C A T I O N

G O V T O R A / E R E V W R S

U B

A P

P R

O V

A L

N E

E D

B Y

M A

N E

E D

B Y

A C T I O N C O D E

D A

F A

O N

D A

W D

P P

R A

D A

C D

M C

O N

D A

W D

R R

E V

E R

D A

C D

M O

E V

E R

A C T I O N C O D E

D A

F A

O N

M A

C O

D A

C D

A P

P R

A U

E M

A R

K S

(f) (g

(i)

(j) (k

(l)

PN102707

Ozark Powerhouse, Ozark Lock and Dam

B M

R M

,J an

P R

E V

S E

B S

A G

O F

A G

E S

Tr ea te d

W at er P la nt

R eh ab

P lu m bi ng S ys te m S

D -0

P ro du ct D at a

G Fi lte r S ys te m 1.

W el di ng

S D

-0

Te st

R ep or ts

Te st s an d Fl us hi ng S

D -0

C er tif ic at es 1.

M at er ia ls a nd

E qu ip m en t

B ol ts S

D -1

O pe ra tio n an d

M ai nt en an ce

D at a 3.

G P lu m bi ng

S ys te m

S D

-0

S ho p D ra w in gs

P ip e In su la tio n

S ys te m s 3.

P ip e

In su la tio n S ys te m s

E qu ip m en t I ns ul at io n S ys te m s

S D

-0

P ro du ct

D at a C er tif ic at io n

G P ip e

In su la tio n S ys te m s

G P ip e

In su la tio n S ys te m s

G E qu ip m en t I ns ul at io n

S ys te m s S

D -0

M an uf ac tu re r’s

In st ru ct io ns

P ip e In su la tio n

S ys te m s 3.

P ip e

In su la tio n S ys te m s

E qu ip m en t I ns ul at io n S ys te m s

D -0

P re co ns tru ct io n S ub m itt al s

R C

O N

C T

N O

E A

N D

L O

C A

N C

O N

C O

A C

C H

E D

D A

C O

A C

N A

P P

R O

G A

O R

A C T I V I T Y N O

T R A N S M I T T A L N O

S P E C S E C T

D E

S C

M S

U B

P A R A G R A P H

C L A S S I F I C A T I O N

G O V T O R A / E R E V W R S

U B

A P

P R

O V

A L

N E

E D

B Y

M A

N E

E D

B Y

A C T I O N C O D E

D A

F A

O N

D A

W D

P P

R A

D A

C D

M C

O N

D A

W D

R R

E V

E R

D A

C D

M O

E V

E R

A C T I O N C O D E

D A

F A

O N

M A

C O

D A

C D

A P

P R

A U

E M

A R

K S

(f) (g

(i)

(j) (k

(l)

PN102707

Ozark Powerhouse, Ozark Lock and Dam

B M

R M

,J an

P R

E V

S E

B S

A G

O F

A G

E S

Tr ea te d

W at er P la nt

R eh ab

M at er ia l, E qu ip m en t, an d Fi xt ur e Li st s

S D

-0

P ro du ct

D at a 2.

G C on du its a nd R ac ew ay s

W ire a nd

C ab le 3.

S pl ic es a nd

C on ne ct or s

S w itc he s 2.

G C irc ui t B re ak er s S

D -0

Te st R ep or ts 3.

C on tin ui ty T es t

G In su la tio n

R es is ta nc e

Te st

S D

-0

C er tif ic at es

G C er tif ic at io n

S D

-0

M an uf ac tu re r’s In st ru ct io ns P ar t 2

G M an uf ac tu re r's

In st ru ct io nsSU

B M

L R

C O

A C

T N

E A

N D

L O

C A

N C

O N

C O

A C

C H

E D

D A

C O

A C

N A

P P

R O

G A

O R

A C T I V I T Y N O

T R A N S M I T T A L N O

S P E C S E C T

D E

S C

M S

U B

P A R A G R A P H

C L A S S I F I C A T I O N

G O V T O R A / E R E V W R S

U B

A P

P R

O V

A L

N E

E D

B Y

M A

N E

E D

B Y

A C T I O N C O D E

D A

F A

O N

D A

W D

P P

R A

D A

C D

M C

O N

D A

W D

R R

E V

E R

D A

C D

M O

E V

E R

A C T I O N C O D E

D A

F A

O N

M A

C O

D A

C D

A P

P R

A U

E M

A R

K S

(f) (g

(i)

(j) (k

(l)

PN102707

Ozark Powerhouse, Ozark Lock and Dam

I ce rt if y th at t he a bo ve s ub m it te d it em s ha ve b ee n re vi ew ed in d et ai l a nd a re c or re ct a nd in s tr ic t co nf or m an ce w it h th e co nt ra ct d ra w in gs a nd s pe ci fi ca ti on s ex ce pt a s ot he r w is e st at ed

C H

K O

N E:

T H

I S A

T R A

N S M

T A

L T H

I S A

U B M

T A

R A

N S M

T A

D A

T E

A R K S

C O

N T R A

C T R

E D

O C

U M

N S

(C ov er o nl y on e se ct io n w it h ea ch t ra ns m it ta l)

T O

O M

T T

A N

D L

O C

A T

C O

N T R A

C T N

S U

U R N

Li st b y It em

N o.

T R A

N S M

T A

L O

F S H

O P

D R A

G S

T D

A T A

A T

S A

R M

A N

C T U

'S C

O F

C O

C E

(R ea d in st ru ct io ns o n th e re ve rs e si de p rio r to in it ia ti ng t hi s fo rm

N I R

T F

O R A

R O

V A

L O

F T H

S (T hi s se ct io n w ill b e in it ia te d by t he c on tr ac to r)

T R A

N S M

T A

L N

N A

M E, T

N D

N A

T U

R E

O F

R O

G A

U T H

O R

Y D

A T E

N I I A

R O

V A

L A

C T

N O a.

C R

N O

U B M

(T yp e si ze m od el n um be r/ et c.

O R C

O N

T R

C A

T C

U R V

E D

R A

G O

R B R O

C H

U R E

N O

(S ee in st ru ct io n no c.

N O

F C

R A

O e.

D R A

G S H

T N

O f.

N T R A

C T O

R U

S E

C O

D E g.

V A

N (S ee in st ru ct io n N o.

C E

U S E

C O

D E i.

N A

M E

A N

D S

A T U

R E

O F

C O

N T R A

C T O

F O

R M

-R

A R

(P ro po ne nt

P-

C E)

O F

I S O

B S O

T E.

(E R

-1

C H

K O

N E:

T H

R A

N S M

T A

V 'T

R O

V A

PN102707

Ozark Powerhouse, Ozark Lock and Dam

T R U

C T

N S

S ec ti on

I w ill b e in it ia te d by t he C on tr ac to r in t he r eq ui re d nu m be r of c op ie s.

Ea ch t ra ns m it ta l s ha ll be n um be re d co ns ec ut iv el y in t he s pa ce p ro vi de d fo r "T ra ns m it ta l N o.

T hi s nu m be r, in a dd it io n to t he c on tr ac t nu m be r, w ill f or m a s er ia l nu m be r fo r id en ti fy in g ea ch s ub m it ta l.

F or n ew s ub m it ta ls o r re su bm it ta ls m ar k th e ap pr op ria te b ox on r es ub m it ta ls in se rt t ra ns m it ta l n um be r of la st s ub m is si on a s w el l a s th e ne w s ub m it ta l n um be r.

T he

It em

N o.

w ill b e th e sa m e

"I te m N o.

as in di ca te d on E

N G

F O

R M

-R f or e ac h en tr y on t hi s fo rm

S ub m it ta ls r eq ui rin g ex pe di ti ou s ha nd lin g w ill b e su bm it te d on a s ep ar at e fo rm

S ep ar at e tr an sm it ta l f or m w ill b e us ed f or s ub m it ta ls u nd er s ep ar at e se ct io ns o f th e sp ec if ic at io ns

A c he ck s ha ll be p la ce d in t he

V ar ia ti on co lu m n w he n a su bm it ta l i s no t in a cc or da nc e w it h th e pl an s an d sp ec if ic at io ns al so a w rit te n st at em en t to t ha t ef fe ct sh al l b e in cl ud ed in t he s pa ce p ro vi de d fo r "R em ar ks

Fo rm is s el f-tr an sm it ta l, le tt er o f tr an sm it ta l i s no t re qu ire d.

W he n a sa m pl e of m at er ia l o r M an uf ac tu re r' s C er ti fi ca te o f C om pl ia nc e is t ra ns m it te d, in di ca te

S am pl e" o r

"C er ti fi ca te in c ol um n c, S ec ti on

U .S

A rm y

C or ps o f En gi ne er s ap pr ov in g au th or it y w ill a ss ig n ac ti on c od es a s in di ca te d be lo w in s pa ce p ro vi de d in S ec ti on

I co lu m n i t o ea ch it em s ub m it te d.

In ad di ti on t he y w ill e ns ur e en cl os ur es a re in di ca te d an d at ta ch ed t o th e fo rm p rio r to r et ur n to t he c on tr ac to r.

C on tr ac to r w ill a ss ig n ac ti on c od es a s in di ca te d be lo w in

S ec ti on

I co lu m n g, t o ea ch it em s ub m it te

d. T H

G A

C T

N C

O D

R E

O I T

S S

U B M

A pp ro ve d as s ub m it te d.

A pp ro ve d, e xc ep t as n ot ed o n dr aw in gs

R ef er t o at ta ch ed s he et r es ub m is si on r eq ui re d.

W ill b e re tu rn ed b y se pa ra te c or re sp on de nc e.

A pp ro va l o f it em s do es n ot r el ie ve t he c on tr ac to r fr om c om pl yi ng w it h al l t he r eq ui re m en ts o f th e co nt ra ct p la ns a nd s pe ci fic at io ns

(R ev er se o f

F or m

-R

D is ap pr ov ed

S ee a tt ac he d)

R ec ei pt a ck no w le dg ed

R ec ei pt a ck no w le dg ed do es n ot c om pl y as n ot ed w it h co nt ra ct r eq ui re m en ts

O th er

S pe ci fy

PN102707

Ozark Powerhouse, Ozark Lock and Dam

H A

Z A

R D

A N

A L

N T

R A

C T

N O

C A

A T

E D

S T

A R

T D

A L

S T

N T

S A

Y /H

E A

L T

H H

R D

S R

E C

O M

M E

N D

E D

C O

N T

R O

L S

Id en tif y th e pr in ci pa l s te ps in vo lv ed a nd th e se qu en ce o f w or k ac tiv iti es

An al yz e ea ch p ri nc ip al st ep fo r p ot en tia l h az ar ds ev el op sp ec ifi c co nt ro ls fo r e ac h po te nt ia l h az ar d

M E

N T

T O

B E

E C

N R

E Q

E M

E N

T S

T R

R E

Q U

M E

N T

S Li st e qu ip m en t t o be u se d in th e w or k ac tiv ity

Li st in sp ec tio n re qu ir em en ts fo r t he w or k ac tiv ity

Li st tr ai ni ng re qu ir em en ts , i nc lu di ng h az ar d co m m un ic at io n

N T

R A

C T

O R

(S ig na tu re d at e)

PN102707

Ozark Powerhouse, Ozark Lock and Dam

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)

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

PN102707

Ozark Powerhouse, Ozark Lock and Dam 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

DATECOMMANDER SIGNATURE

TITLE

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. 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

Ozark Powerhouse, Ozark Lock and Dam

ACCIDENT DESCRIPTION (Continuation)

DIRECT CAUSE (Continuation)

10.

13a.

Page 3 of 4 pages

PN102707

Ozark Powerhouse, Ozark Lock and Dam

INDIRECT CAUSES (Continuation)

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

13b.

14.

Page 4 of 4 pages

PN102707

Ozark Powerhouse, Ozark Lock and Dam

THIS PAGE INTENTIONALLY LEFT BLANK

Ozark Powerhouse, Ozark Lock and Dam

H A

F o rm s fo r

R e c o rd in g W o rk

-R e la te d I n ju ri e s a n d

I ll n e ss e s

W h a t’ s

In si d e

In th is p ac k ag e, yo u ’l l fi n d ev er yt h in g yo u n ee d to co m p le te

O S

H A

’s an d th e fo r th e n e x t se ve ra l ye ar s.

O n th e fo ll o w in g p ag es yo u ’l l fi n d

G en er al in st ru ct io n s fo r fi ll in g o u t th e fo rm s in th is p ac k ag e an d d ef in it io n s o f te rm s yo u sh o u ld u se w h en yo u cl as si fy yo u r ca se s as in ju ri es o r il ln es se s.

A n e x am p le to g u id e yo u in fi ll in g o u t th e p ro p er ly

S ev er al p ag es o f th e

(b u t yo u m ay m ak e as m an y co p ie s o f th e as yo u n ee d

N o ti ce th at th e is se p ar at e fr o m th e

R em o va b le p ag es fo r ea sy p o st in g at th e en d o f th e ye ar

N o te th at yo u p o st th e o n ly n o t th e

A w o rk sh ee t fo r fi g u ri n g th e av er ag e n u m b er o f em p lo ye es w h o w o rk ed fo r yo u r es ta b li sh m en t an d th e to ta l n u m b er o f h o u rs w o rk ed

A co p y o f th e

O S

H A to p ro vi d e d et ai ls ab o u t th e in ci d en t.

Y o u m ay m ak e as m an y co p ie s as yo u n ee d o r u se an eq u iv al en t fo rm

T ak e a fe w m in u te s to re vi ew th is p ac k ag e.

If yo u h av e an y q u es ti o n s, W e’ ll b e h ap p y to h el p yo u

L og

S u m m ar y of W or k-

R el at ed

In ju ri es an d

Il ln es se s

L og

S u m m ar y.

S u m m ar y

L og

A n

O ve rv ie w R e c o rd in g

W o rk -R e la te d

I n ju ri e s a n d I ll n e ss e s

H o w t o F il l O u t th e

L o g

L o g o f W o rk

-R e la te d I n ju ri e s a n d

Il ln e ss e s

S u m m a ry o f

W o rk -R e la te d

I n ju ri e s a n d Il ln e ss e s

W o rk sh e e t to

H e lp Y o u

F il l O u t th e

S u m m a ry

O S

H A

’s

In ju ry a n d I ll n e ss

I n c id e n t R e p o rt o r vi si t u s o n li n e a t w w w .o sh a g o v c a ll y o u r lo c a l O

S H

A o ff ic e

U.S. Department of Labor Occupational Safety and Health Administration

D e a r

E m p lo ye r:

T h is b o o k le t in cl u d es th e fo rm s n ee d ed fo r m ai n ta in in g o cc u p at io n al in ju ry an d il ln es s re co rd s fo r

T h es e n ew fo rm s h av e ch an g ed in se ve ra l im p o rt an t w ay s fr o m th e re co rd k ee p in g fo rm s.

In th e

O S

H A an n o u n ce d it s d ec is io n to ad d an o cc u p at io n al h ea ri n g lo ss co lu m n to

O S

H A

’s F o rm

L o g o f

W o rk -R el at ed In ju ri es an d Il ln es se s.

T h is fo rm s p ac k ag e co n ta in s m o d if ie d

F o rm s an d

A w h ic h in co rp o ra te th e ad d it io n al co lu m n M

H ea ri n g L o ss

E m p lo ye rs re q u ir ed to co m p le te th e in ju ry an d il ln es s fo rm s m u st b eg in to u se th es e fo rm s o n

Ja n u ar y

In re sp o n se to p u b li c su g g es ti o n s, O

S H

A al so h as m ad e se ve ra l ch an g es to th e fo rm s p ac k ag e to m ak e th e re co rd k ee p in g m at er ia ls cl ea re r an d ea si er to u se

O n F o rm w e’ ve sw it ch ed th e p o si ti o n s o f th e d ay co u n t co lu m n s.

T h e d ay s

“a w ay fr o m w o rk co lu m n n o w co m es b ef o re th e d ay s “o n jo b tr an sf er o r re st ri ct io n

W e’ ve cl ar if ie d th e fo rm u la s fo r ca lc u la ti n g in ci d en ce ra te s.

W e’ ve ad d ed n ew re co rd in g cr it er ia fo r o cc u p at io n al h ea ri n g lo ss to th e

“O ve rv ie w se ct io n

O n F o rm w e’ ve m ad e th e co lu m n h ea d in g

“C la ss if y th e C as e” m o re p ro m in en t to m ak e it cl ea r th at em p lo ye rs sh o u ld m ar k o n ly o n e se le ct io n am o n g th e fo u r co lu m n s o ff er ed

T h e O cc u p at io n al S af et y an d H ea lt h A d m in is tr at io n sh ar es w it h yo u th e g o al o f p re ve n ti n g in ju ri es an d il ln es se s in o u r n at io n ’s w o rk p la ce s.

A cc u ra te in ju ry an d il ln es s re co rd s w il l h el p u s ac h ie ve th at g o al

D ec em b er

F ed er al R eg is te r

F R

-7

O cc u pa ti on al S af et y an d H ea lt h A dm in is tr at io n

U .S

D ep ar tm en t of

L ab or

PN102707

Ozark Powerhouse, Ozark Lock and Dam h e (F o rm is u se d to cl as si fy w o rk

-r el at ed in ju ri es an d il ln es se s an d to n o te th e e x te n t an d se ve ri ty o f ea ch ca se

W h en an in ci d en t o cc u rs u se th e to re co rd sp ec if ic d et ai ls ab o u t w h at h ap p en ed an d h o w it h ap p en ed

T h e a se p ar at e fo rm

(F o rm

A sh o w s th e to ta ls fo r th e ye ar in ea ch ca te g o ry

A t th e en d o f th e ye ar p o st th e in a vi si b le lo ca ti o n so th at yo u r em p lo ye es ar e aw ar e o f th e in ju ri es an d il ln es se s o cc u rr in g in th ei r w o rk p la ce

E m p lo ye rs m u st k ee p a fo r ea ch es ta b li sh m en t o r si te

If yo u h av e m o re th an o n e es ta b li sh m en t, yo u m u st k ee p a se p ar at e an d fo r ea ch p h ys ic al lo ca ti o n th at is e x p ec te d to b e in o p er at io n fo r o n e ye ar o r lo n g er

N o te th at yo u r em p lo ye es h av e th e ri g h t to re vi ew yo u r in ju ry an d il ln es s re co rd s.

F o r m o re in fo rm at io n se e

C o d e o f F ed er al R eg u la ti o n s P ar t

C as es li st ed o n th e ar e n o t n ec es sa ri ly el ig ib le fo r w o rk er s’ co m p en sa ti o n o r o th er in su ra n ce b en ef it s.

L is ti n g a ca se o n th e d o es n o t m ea n th at th e em p lo ye r o r w o rk er w as at fa u lt o r th at an

O S

H A st an d ar d w as vi o la te d

R ec o rd th o se w o rk

-r el at ed in ju ri es an d il ln es se s th at re su lt in d ea th lo ss o f co n sc io u sn es s, d ay s aw ay fr o m w o rk re st ri ct ed w o rk ac ti vi ty o r jo b tr an sf er o r m ed ic al tr ea tm en t b ey o n d fi rs t ai d

Y o u m u st al so re co rd w o rk

-r el at ed in ju ri es an d il ln es se s th at ar e si g n if ic an t

(a s d ef in ed b el o w o r m ee t an y o f th e ad d it io n al cr it er ia li st ed b el o w

L og of W or k-

R el at ed

In ju ri es an d

Il ln es se s

L og

S u m m ar y

L og

S u m m ar y

E m pl oy ee In vo lv em en t.

L og of W or k-

R el at ed

In ju ri es an d

Il ln es se s

L og

W h e n i s a n i n ju ry o r il ln e ss c o n si d e re d w o rk -r e la te d

W h ic h w o rk -r e la te d i n ju ri e s a n d il ln e ss e s sh o u ld y o u r e c o rd

A n in ju ry o r il ln es s is co n si d er ed w o rk -r el at ed if an ev en t o r e x p o su re in th e w o rk en vi ro n m en t ca u se d o r co n tr ib u te d to th e co n d it io n o r si g n if ic an tl y ag g ra va te d a p re e x is ti n g co n d it io n

W o rk

-r el at ed n es s is p re su m ed fo r in ju ri es an d il ln es se s re su lt in g fr o m ev en ts o r e x p o su re s o cc u rr in g in th e w o rk p la ce u n le ss an e x ce p ti o n sp ec if ic al ly ap p li es

S ee

F R

P ar t

(b fo r th e e x ce p ti o n s.

T h e w o rk en vi ro n m en t in cl u d es th e es ta b li sh m en t an d o th er lo ca ti o n s w h er e o n e o r m o re em p lo ye es ar e w o rk in g o r ar e p re se n t as a co n d it io n o f th ei r em p lo ym en t.

S ee

C F

R P ar t

.5 (b

Y o u m u st re co rd an y si g n if ic an t w o rk re la te d in ju ry o r il ln es s th at is d ia g n o se d b y a p h ys ic ia n o r o th er li ce n se d h ea lt h ca re p ro fe ss io n al

Y o u m u st re co rd an y w o rk

-r el at ed ca se in vo lv in g ca n ce r, ch ro n ic ir re ve rs ib le d is ea se a fr ac tu re d o r cr ac k ed b o n e, o r a p u n ct u re d ea rd ru m

S ee

C F

Y o u m u st re co rd th e fo ll o w in g co n d it io n s w h en th ey ar e w o rk

-r el at ed an y n ee d le st ic k in ju ry o r cu t fr o m a sh ar p o b je ct th at is co n ta m in at ed w it h an o th er p er so n

’s b lo o d o r o th er p o te n ti al ly in fe ct io u s m at er ia l;

an y ca se re q u ir in g an em p lo ye e to b e m ed ic al ly re m o ve d u n d er th e re q u ir em en ts o f an

O S

H A h ea lt h st an d ar d tu b er cu lo si s in fe ct io n as ev id en ce d b y a p o si ti ve sk in te st o r d ia g n o si s b y a p h ys ic ia n o r o th er li ce n se d h ea lt h ca re p ro fe ss io n al af te r e x p o su re to a k n o w n ca se o f ac ti ve tu b er cu lo si s.

an em p lo ye e' s h ea ri n g te st

(a u d io g ra m re ve al s th at th e em p lo ye e h as e x p er ie n ce d a S ta n d ar d T h re sh o ld S h if t (S

T S in h ea ri n g in o n e o r b o th ea rs (a ve ra g ed at an d

z) an d th e em p lo ye e' s to ta l h ea ri n g le ve l is d ec ib el s

(d B o r m o re ab o ve au d io m et ri c ze ro al so av er ag ed at an d

H z) in th e sa m e ea r(

s) as th e

S T

M ed ic al tr ea tm en t in cl u d es m an ag in g an d ca ri n g fo r a p at ie n t fo r th e p u rp o se o f co m b at in g d is ea se o r d is o rd er

T h e fo ll o w in g ar e n o t co n si d er ed m ed ic al tr ea tm en ts an d ar e N

O T re co rd ab le vi si ts to a d o ct o r o r h ea lt h ca re p ro fe ss io n al so le ly fo r o b se rv at io n o r co u n se li n g

W h a t a re t h e a d d it io n a l c ri te ri a

W h a t is m e d ic a l tr e a tm e n t?

A n

O ve rv ie w

R e c o rd in g W o rk

-R e la te d I n ju ri e s a n d

I ll n e ss e s

W h a t d o y o u n e e d t o d o

W it h in ca le n d ar d ay s af te r yo u re ce iv e in fo rm at io n ab o u t a ca se d ec id e if th e ca se is re co rd ab le u n d er th e O

S H

A re co rd k ee p in g re q u ir em en ts

D et er m in e w h et h er th e in ci d en t is a n ew ca se o r a re cu rr en ce o f an e x is ti n g o n e.

d en ti fy th e em p lo ye e in vo lv ed u n le ss it is a p ri va cy co n ce rn ca se as d es cr ib ed b el o w d en ti fy w h en an d w h er e th e ca se o cc u rr ed

D es cr ib e th e ca se as sp ec if ic al ly as yo u ca n

Id en ti fy w h et h er th e ca se is an in ju ry o r il ln es s.

If th e ca se is an in ju ry ch ec k th e in ju ry ca te g o ry

If th e ca se is an il ln es s, ch ec k th e ap p ro p ri at e il ln es s ca te g o ry

E st ab li sh w h et h er th e ca se w as w o rk re la te d

If th e ca se is re co rd ab le d ec id e w h ic h fo rm yo u w il l fi ll o u t as th e in ju ry an d il ln es s in ci d en t re p o rt

Y o u m ay u se o r an eq u iv al en t fo rm

S o m e st at e w o rk er s co m p en sa ti o n in su ra n ce o r o th er re p o rt s m ay b e ac ce p ta b le su b st it u te s, as lo n g as th ey p ro vi d e th e sa m e in fo rm at io n as th e

O S

H A

I I C la ss if y th e se ri o u sn es s o f th e ca se b y re co rd in g th e as so ci at ed w it h th e ca se w it h co lu m n

G (D ea th b ei n g th e m o st se ri o u s an d co lu m n

J (O th er re co rd ab le ca se s) b ei n g th e le as t se ri o u s.

O S

H A

’s

In ju ry an d Il ln es s In ci de n t R ep or t

H o w t o w o rk w it h t h e

L o g m o st se ri o u s o u tc o m e

Th e

O cc up at io na l S af et y an d

H ea lth (O

) A ct o f 1 re qu ire s ce rta in e m pl oy er s to p re pa re a nd m ai nt ai n re co rd s of w or k-re la te d in ju rie s an d ill ne ss es

. U se th es e de fin iti on s w he n yo u cl as si fy c as es o n th e

Lo g.

A’ s re co rd ke ep in g re gu la tio n

(s ee

P ar t 1

4) p ro vi de s m or e in fo rm at io n ab ou t t he d ef in iti on s be lo w

U.S. Department of Labor Occupational Safety and Health Administration

PN102707

Ozark Powerhouse, Ozark Lock and Dam d ia g n o st ic p ro ce d u re s, in cl u d in g ad m in is te ri n g p re sc ri p ti o n m ed ic at io n s th at ar e u se d so le ly fo r d ia g n o st ic p u rp o se s;

an d an y p ro ce d u re th at ca n b e la b el ed fi rs t ai d

Y o u m u st co n si d er th e fo ll o w in g ty p es o f in ju ri es o r il ln es se s to b e p ri va cy co n ce rn ca se s:

an in ju ry o r il ln es s to an in ti m at e b o d y p ar t o r to th e re p ro d u ct iv e sy st em an in ju ry o r il ln es s re su lt in g fr o m a se x u al as sa u lt a m en ta l il ln es s, a ca se o f H

in fe ct io n h ep at it is o r tu b er cu lo si s, a n ee d le st ic k in ju ry o r cu t fr o m a sh ar p o b je ct th at is co n ta m in at ed w it h b lo o d o r o th er p o te n ti al ly in fe ct io u s m at er ia l (s ee

C F

R P ar t

.8 fo r d ef in it io n an d o th er il ln es se s, if th e em p lo ye e in d ep en d en tl y an d vo lu n ta ri ly re q u es ts th at h is o r h er n am e n o t b e en te re d o n th e lo g

Y o u m u st n o t en te r th e em p lo ye e’ s n am e o n th e

O S

H A fo r th es e ca se s.

In st ea d en te r

“p ri va cy ca se in th e sp ac e n o rm al ly u se d fo r th e em p lo ye e’ s n am e.

Y o u m u st k ee p a se p ar at e, co n fi d en ti al li st o f th e ca se n u m b er s an d em p lo ye e n am es fo r th e es ta b li sh m en t’ s p ri va cy co n ce rn ca se s so th at yo u ca n u p d at e th e ca se s an d p ro vi d e in fo rm at io n to th e g o ve rn m en t if as k ed to d o so

If yo u h av e a re as o n ab le b as is to b el ie ve th at in fo rm at io n d es cr ib in g th e p ri va cy co n ce rn ca se m ay b e p er so n al ly id en ti fi ab le ev en th o u g h th e em p lo ye e’ s n am e h as b ee n o m it te d yo u m ay u se d is cr et io n in d es cr ib in g th e in ju ry o r il ln es s o n b o th th e O

S H

A an d fo rm s.

Y o u m u st en te r en o u g h in fo rm at io n to id en ti fy th e ca u se o f th e in ci d en t an d th e g en er al se ve ri ty o f th e in ju ry o r il ln es s, b u t yo u d o n o t n ee d to in cl u d e d et ai ls o f an in ti m at e o r p ri va te n at u re co n tu si o n ch ip p ed to o th

S ee be lo w fo r m or e in fo rm at io n ab ou t fi rs t ai d.

L og

U n d e r w h a t c ir c u m st a n c e s sh o u ld y o u N

O T e n te r th e e m p lo ye e

’s n a m e o n t h e

O S

H A

F o rm

C la ss if yi n g i n ju ri e s

A n in ju ry is an y w o u n d o r d am ag e to th e b o d y re su lt in g fr o m an ev en t in th e w o rk en vi ro n m en t.

C u t, p u n ct u re la ce ra ti o n ab ra si o n fr ac tu re b ru is e, am p u ta ti o n in se ct b it e, el ec tr o cu ti o n o r a th er m al ch em ic al el ec tr ic al o r ra d ia ti o n b u rn

S p ra in an d st ra in in ju ri es to m u sc le s, jo in ts an d co n n ec ti ve ti ss u es ar e cl as si fi ed as in ju ri es w h en th ey re su lt fr o m a sl ip tr ip fa ll o r o th er si m il ar ac ci d en ts

E xa m p le s:

W h a t is f ir st a id

If th e in ci d en t re q u ir ed o n ly th e fo ll o w in g ty p es o f tr ea tm en t, co n si d er it fi rs t ai d

D o N

O T re co rd th e ca se if it in vo lv es o n ly u si n g n o n -p re sc ri p ti o n m ed ic at io n s at n o n p re sc ri p ti o n st re n g th ad m in is te ri n g te ta n u s im m u n iz at io n s;

cl ea n in g fl u sh in g o r so ak in g w o u n d s o n th e sk in su rf ac e;

u si n g w o u n d co ve ri n g s, su ch as b an d ag es

B an d A id s™ g au ze p ad s, et c.

o r u si n g

S te ri S tr ip s™ o r b u tt er fl y b an d ag es u si n g h o t o r co ld th er ap y;

u si n g an y to ta ll y n o n -r ig id m ea n s o f su p p o rt su ch as el as ti c b an d ag es w ra p s, n o n -r ig id b ac k b el ts et c.

u si n g te m p o ra ry im m o b il iz at io n d ev ic es w h il e tr an sp o rt in g an ac ci d en t vi ct im

(s p li n ts sl in g s, n ec k co ll ar s, o r b ac k b o ar d s) d ri ll in g a fi n g er n ai l o r to en ai l to re li ev e p re ss u re o r d ra in in g fl u id s fr o m b li st er s;

u si n g ey e p at ch es u si n g si m p le ir ri g at io n o r a co tt o n sw ab to re m o ve fo re ig n b o d ie s n o t em b ed d ed in o r ad h er ed to th e ey e;

u si n g ir ri g at io n tw ee ze rs co tt o n sw ab o r o th er si m p le m ea n s to re m o ve sp li n te rs o r fo re ig n m at er ia l fr o m ar ea s o th er th an th e ey e;

u si n g fi n g er g u ar d s;

u si n g m as sa g es d ri n k in g fl u id s to re li ev e h ea t st re ss

R es tr ic te d w o rk ac ti vi ty o cc u rs w h en as th e re su lt o f a w o rk -r el at ed in ju ry o r il ln es s, an em p lo ye r o r h ea lt h ca re p ro fe ss io n al k ee p s, o r re co m m en d s k ee p in g an em p lo ye e fr o m d o in g th e ro u ti n e fu n ct io n s o f h is o r h er jo b o r fr o m w o rk in g th e fu ll w o rk d ay th at th e em p lo ye e w o u ld h av e b ee n sc h ed u le d to w o rk b ef o re th e in ju ry o r il ln es s o cc u rr ed

If th e o u tc o m e o r e x te n t o f an in ju ry o r il ln es s ch an g es af te r yo u h av e re co rd ed th e ca se si m p ly d ra w a li n e th ro u g h th e o ri g in al en tr y o r, if yo u w is h d el et e o r w h it e-o u t th e o ri g in al en tr y.

T h en w ri te th e n ew en tr y w h er e it b el o n g s.

R em em b er yo u n ee d to re co rd th e m o st se ri o u s o u tc o m e fo r ea ch ca se

� � � H o w d o y o u d e c id e i f th e c a se i n vo lv e d re st ri c te d w o rk

H o w d o y o u c o u n t th e n u m b e r o f d a ys o f re st ri c te d w o rk a c ti vi ty o r th e n u m b e r o f d a ys a w a y fr o m w o rk

W h a t if t h e o u tc o m e c h a n g e s a ft e r yo u re c o rd t h e c a se

C o u n t th e n u m b er o f ca le n d ar d ay s th e em p lo ye e w as o n re st ri ct ed w o rk ac ti vi ty o r w as aw ay fr o m w o rk as a re su lt o f th e re co rd ab le in ju ry o r il ln es s.

D o n o t co u n t th e d ay o n w h ic h th e in ju ry o r il ln es s o cc u rr ed in th is n u m b er

B eg in co u n ti n g d ay s fr o m th e d ay th e in ci d en t o cc u rs

If a si n g le in ju ry o r il ln es s in vo lv ed b o th d ay s aw ay fr o m w o rk an d d ay s o f re st ri ct ed w o rk ac ti vi ty en te r th e to ta l n u m b er o f d ay s fo r ea ch

Y o u m ay st o p co u n ti n g d ay s o f re st ri ct ed w o rk ac ti vi ty o r d ay s aw ay fr o m w o rk o n ce th e to ta l o f ei th er o r th e co m b in at io n o f b o th re ac h es d ay s.

af te r

U.S. Department of Labor Occupational Safety and Health Administration

PN102707

Ozark Powerhouse, Ozark Lock and Dam la ss if yi n g i ll n e ss e s

S k in d is e a se s o r d is o rd e rs

R e sp ir a to ry c o n d it io n s

H e a ri n g

L o ss

A ll o th e r il ln e ss e s

S k in d is ea se s o r d is o rd er s ar e il ln es se s in vo lv in g th e w o rk er

’s sk in th at ar e ca u se d b y w o rk e x p o su re to ch em ic al s, p la n ts o r o th er su b st an ce s.

C o n ta ct d er m at it is ec ze m a, o r ra sh ca u se d b y p ri m ar y ir ri ta n ts an d se n si ti ze rs o r p o is o n o u s p la n ts o il ac n e;

fr ic ti o n b li st er s, ch ro m e u lc er s;

in fl am m at io n o f th e sk in

R es p ir at o ry co n d it io n s ar e il ln es se s as so ci at ed w it h b re at h in g h az ar d o u s b io lo g ic al ag en ts ch em ic al s, d u st g as es va p o rs o r fu m es at w o rk

S il ic o si s, as b es to si s, p n eu m o n it is p h ar yn g it is rh in it is o r ac u te co n g es ti o n fa rm er ’s lu n g b er yl li u m d is ea se tu b er cu lo si s, o cc u p at io n al as th m a, re ac ti ve ai rw ay s d ys fu n ct io n sy n d ro m e (R

A D

S ch ro n ic o b st ru ct iv e p u lm o n ar y d is ea se (C

O P

D h yp er se n si ti vi ty p n eu m o n it is to x ic in h al at io n in ju ry su ch as m et al fu m e fe ve r, ch ro n ic o b st ru ct iv e b ro n ch it is an d o th er p n eu m o co n io se s.

N o is e-in d u ce d h ea ri n g lo ss is d ef in ed fo r re co rd k ee p in g p u rp o se s as a ch an g e in h ea ri n g th re sh o ld re la ti ve to th e b as el in e au d io g ra m o f an av er ag e o f d

B o r m o re in ei th er ea r at an d h er tz

A ll o th er o cc u p at io n al il ln es se s.

H ea ts tr o k e, su n st ro k e, h ea t e x h au st io n h ea t st re ss an d o th er ef fe ct s o f en vi ro n m en ta l h ea t;

fr ee zi n g fr o st b it e, an d o th er ef fe ct s o f e x p o su re to lo w te m p er at u re s;

d ec o m p re ss io n si ck n es s;

ef fe ct s o f io n iz in g ra d ia ti o n

(i so to p es x -r ay s, ra d iu m ef fe ct s o f n o n io n iz in g ra d ia ti o n

(w el d in g fl as h u lt ra

-v io le t ra ys la se rs an th ra x b lo o d b o rn e p at h o g en ic d is ea se s, su ch as

h ep at it is

B o r h ep at it is C b ru ce ll o si s;

m al ig n an t o r

E xa m p le s:

P o is o n in g P o is o n in g in cl u d es d is o rd er s ev id en ce d b y ab n o rm al co n ce n tr at io n s o f to x ic su b st an ce s in b lo o d o th er ti ss u es o th er b o d il y fl u id s, o r th e b re at h th at ar e ca u se d b y th e in g es ti o n o r ab so rp ti o n o f to x ic su b st an ce s in to th e b o d y.

P o is o n in g b y le ad m er cu ry ca d m iu m ar se n ic o r o th er m et al s;

p o is o n in g b y ca rb o n m o n o x id e, h yd ro g en su lf id e, o r o th er g as es p o is o n in g b y b en ze n e, b en zo l, ca rb o n te tr ac h lo ri d e, o r o th er o rg an ic so lv en ts p o is o n in g b y in se ct ic id e sp ra ys su ch as p ar at h io n o r le ad ar se n at e;

p o is o n in g b y o th er ch em ic al s, su ch as fo rm al d eh yd e.

E xa m p le s:

b en ig n tu m o rs h is to p la sm o si s;

co cc id io id o m yc o si s.

,a n d th e em p lo ye e’ s to ta l h ea ri n g le ve l is d ec ib el s (d

B o r m o re ab o ve au d io m et ri c ze ro

(a ls o av er ag ed at an d h er tz in th e sa m e ea r( s)

W h e n m u st y o u p o st t h e

S u m m a ry

H o w l o n g m u st y o u k e e p t h e

L o g a n d

S u m m a ry o n f il e

D o y o u h a ve t o s e n d t h e se f o rm s to O

S H

A a t th e e n d o f th e y e a r?

H o w c a n w e h e lp y o u

Y o u m u st p o st th e o n ly n o t th e b y

F eb ru ar y o f th e ye ar fo ll o w in g th e ye ar co ve re d b y th e fo rm an d k ee p it p o st ed u n ti l

A p ri l o f th at ye ar

Y o u m u st k ee p th e an d fo r ye ar s fo ll o w in g th e ye ar to w h ic h th ey p er ta in

N o

Y o u d o n o t h av e to se n d th e co m p le te d fo rm s to

O S

H A u n le ss sp ec if ic al ly as k ed to d o so

If yo u h av e a q u es ti o n ab o u t h o w to fi ll o u t th e o r

S u m m ar y

L og

S u m m ar y

L og vi si t u s o n li n e a t w w w

.o sh a .g o v c a ll y o u r lo c a l O

S H

A o ff ic e

U.S. Department of Labor Occupational Safety and Health Administration

PN102707

Ozark Powerhouse, Ozark Lock and Dam

W a t is a n i n c id e n c e r a te

H o w d o y o u c a lc u la te a n i n c id e n c e ra te

W h a t c a n I c o m p a re m y in c id e n c e ra te t o

A n in ci d en ce ra te is th e n u m b er o f re co rd ab le in ju ri es an d il ln es se s o cc u rr in g am o n g a g iv en n u m b er o f fu ll

-t im e w o rk er s

(u su al ly fu ll ti m e w o rk er s) o ve r a g iv en p er io d o f ti m e

(u su al ly o n e ye ar

T o ev al u at e yo u r fi rm

’s in ju ry an d il ln es s e x p er ie n ce o ve r ti m e o r to co m p ar e yo u r fi rm

’s e x p er ie n ce w it h th at o f yo u r in d u st ry as a w h o le yo u n ee d to co m p u te yo u r in ci d en ce ra te

B ec au se a sp ec if ic n u m b er o f w o rk er s an d a sp ec if ic p er io d o f ti m e ar e in vo lv ed th es e ra te s ca n h el p yo u id en ti fy p ro b le m s in yo u r w o rk p la ce an d

/o r p ro g re ss yo u m ay h av e m ad e in p re ve n ti n g w o rk re la te d in ju ri es an d il ln es se s.

Y o u ca n co m p u te an o cc u p at io n al in ju ry an d il ln es s in ci d en ce ra te fo r al l re co rd ab le ca se s o r fo r ca se s th at in vo lv ed d ay s aw ay fr o m w o rk fo r yo u r fi rm q u ic k ly an d ea si ly

T h e fo rm u la re q u ir es th at yo u fo ll o w in st ru ct io n s in p ar ag ra p h

(a b el o w fo r th e to ta l re co rd ab le ca se s o r th o se in p ar ag ra p h (b fo r ca se s th at in vo lv ed d ay s aw ay fr o m w o rk fo r b o th ra te s th e in st ru ct io n s in p ar ag ra p h (c

(a co u n t th e n u m b er o f li n e en tr ie s o n yo u r

O S

H A

F o rm o r re fe r to th e O

S H

A F o rm

A an d su m th e en tr ie s fo r co lu m n s (G

(I an d

(b co u n t th e n u m b er o f li n e en tr ie s o n yo u r

O S

H A

F o rm th at re ce iv ed a ch ec k m ar k in co lu m n

(H o r re fe r to th e en tr y fo r co lu m n

(H o n th e

O S

H A

F o rm

R ef er to O

S H

A F o rm

A an d o p ti o n al w o rk sh ee t to ca lc u la te th is n u m b er

Y o u ca n co m p u te th e in ci d en ce ra te fo r al l re co rd ab le ca se s o f in ju ri es an d il ln es se s u si n g th e fo ll o w in g fo rm u la

(T h e

,0 fi g u re in th e fo rm u la re p re se n ts th e n u m b er o f h o u rs em p lo ye es w o rk in g h o u rs p er w ee k w ee k s p er ye ar w o u ld w o rk an d p ro vi d es th e st an d ar d b as e fo r ca lc u la ti n g in ci d en ce ra te s.

Y o u ca n co m p u te th e in ci d en ce ra te fo r re co rd ab le ca se s in vo lv in g d ay s aw ay fr o m w o rk d ay s o f re st ri ct ed w o rk ac ti vi ty o r jo b tr an sf er

(D A

R T u si n g th e fo ll o w in g fo rm u la

Y o u ca n u se th e sa m e fo rm u la to ca lc u la te in ci d en ce ra te s fo r o th er va ri ab le s su ch as ca se s in vo lv in g re st ri ct ed w o rk ac ti vi ty (c o lu m n

(I o n

F o rm

A ca se s in vo lv in g sk in d is o rd er s

(c o lu m n (M

-2 o n

F o rm

A et c.

Ju st su b st it u te th e ap p ro p ri at e to ta l fo r th es e ca se s, fr o m F o rm

A in to th e fo rm u la in p la ce o f th e to ta l n u m b er o f in ju ri es an d il ln es se s.

T h e B u re au o f L ab o r S ta ti st ic s (B

L S co n d u ct s a su rv ey o f o cc u p at io n al in ju ri es an d il ln es se s ea ch ye ar an d p u b li sh es in ci d en ce ra te d at a b y va ri o u s cl as si fi ca ti o n s

(e .g b y in d u st ry b y em p lo ye r si ze et c.

Y o u ca n o b ta in th es e p u b li sh ed d at a at w w w .b ls .g o v/ ii f o r b y ca ll in g a

B L

S R eg io n al

O ff ic e.

an d

To fi n d ou t th e to ta l n u m be r of re co rd ab le in ju ri es an d il ln es se s th at oc cu rr ed du ri n g th e ye ar

To fi n d ou t th e n u m be r of in ju ri es an d il ln es se s th at in vo lv ed da ys aw ay fr om w or k, T he n u m be r of ho u rs al l em pl oy ee s ac tu al ly w or ke d du ri n g th e ye ar

To ta l n u m be r of in ju ri es an d il ln es se s ,0

N u m be r of ho u rs w or ke d by al l em pl oy ee s

To ta l re co rd ab le ca se ra te

(N u m be r of en tr ie s in co lu m n H

N u m be r of en tr ie s in co lu m n I)

N u m be r of ho u rs w or ke d by al l em pl oy ee s

A R

T in ci de n ce ra te

O p ti o n a l

C a lc u la ti n g

I n ju ry a n d I ll n e ss

I n c id e n c e

R a te s

W o rk sh e e t

U.S. Department of Labor Occupational Safety and Health Administration

N u m b er o f en tr ie s in

C o lu m n H

C o lu m n I

D A

R T in ci d en ce ra te

N u m b er o f h o u rs w o rk ed b y al l em p lo ye es

T o ta l n u m b er o f in ju ri es an d il ln es se s

T o ta l re co rd ab le ca se ra te

N u m b er o f h o u rs w o rk ed b y al l em p lo ye es

PN102707

Ozark Powerhouse, Ozark Lock and Dam e is u se d to cl as si fy w o rk -r el at ed in ju ri es an d il ln es se s an d to n o te th e e x te n t an d se ve ri ty o f ea ch ca se

W h en an in ci d en t o cc u rs u se th e to re co rd sp ec if ic d et ai ls ab o u t w h at h ap p en ed an d h o w it h ap p en ed

W e h av e g iv en yo u se ve ra l co p ie s o f th e in th is p ac k ag e.

If yo u n ee d m o re th an w e p ro vi d ed yo u m ay p h o to co p y an d u se as m an y as yo u n ee d

T h e a se p ar at e fo rm sh o w s th e w o rk -r el at ed in ju ry an d il ln es s to ta ls fo r th e ye ar in ea ch ca te g o ry A t th e en d o f th e ye ar co u n t th e n u m b er o f in ci d en ts in ea ch ca te g o ry an d tr an sf er th e to ta ls fr o m th e to th e T h en p o st th e in a vi si b le lo ca ti o n so th at yo u r em p lo ye es ar e aw ar e o f in ju ri es an d il ln es se s o cc u rr in g in th ei r w o rk p la ce

L og of W or k-

R el at ed

In ju ri es an d

Il ln es se s

L og

S u m m ar y

L og

S u m m ar y.

S u m m ar y

If yo u r co m p an y h as m o re th an o n e es ta b li sh m en t o r si te yo u m u st k ee p se p ar at e re co rd s fo r ea ch p h ys ic al lo ca ti o n th at is e x p ec te d to re m ai n in o p er at io n fo r o n e ye ar o r lo n g er

Y o u d o n

’t p o st t h e L o g

Y o u p o st o n ly th e

S u m m a ry a t th e e n d o f th e y e a r.

H o w t o F il l O u t th e

L o g

U.S. Department of Labor Occupational Safety and Health Administration

R e vi se t h e l o g i f th e i n ju ry o r il ln e ss p ro g re ss e s a n d t h e o u tc o m e i s m o re se ri o u s th a n y o u o ri g in a ll y re c o rd e d f o r th e c a se

C ro ss o u t, e ra se o r w h it e -o u t th e o ri g in a l e n tr y.

B e a s sp e c if ic a s p o ss ib le

Y o u c a n u se t w o l in e s if y o u n e e d m o re r o o m

N o te w h e th e r th e c a se i n vo lv e s a n in ju ry o r a n i ll n e ss

C h o o se O

O N

E o f th e se c a te g o ri e s.

C la ss if y th e c a se b y re c o rd in g t h e m o st se ri o u s o u tc o m e o f th e c a se w it h c o lu m n G

D e a th b e in g th e m o st s e ri o u s a n d c o lu m n J

O th e r re c o rd a b le c a se s) b e in g t h e l e a st s e ri o u s.

C h e c k t h e

In ju ry c o lu m n o r c h o o se o n e t yp e o f il ln e ss

D e s c r ib e in ju r y o r il ln e s s, p a r ts o f b o d y a ff e c te d a n d o b je c t/ s u b s ta n c e th a t d ir e c tl y in ju re d o r m a d e p e r s o n il l

Skin disorders

Respiratory conditions

Poisoning

Hearing loss

All other illnesses

Injury

Yo u m us t r ec or d in fo rm at io n ab ou t e ve ry w or k-re la te d de at h an d ab ou t e ve ry w or k-re la te d in ju ry o r i lln es s th at in vo lv es lo ss o f c on sc io us ne ss , r es tri ct ed w or k ac tiv ity o r j ob t ra ns fe r, da ys a w ay fr om w or k, o r m ed ic al tr ea tm en t b ey on d fir st a id . Y ou m us t a ls o re co rd s ig ni fic an t w or k-re la te d in ju rie s an d ill ne ss es th at a re d ia gn os ed b y a ph ys ic ia n or li ce ns ed h ea lth ca re p ro fe ss io na l.

Yo u m us t a ls o re co rd w or k-re la te d in ju rie s an d ill ne ss es th at m ee t a ny o f t he s pe ci fic re co rd in g cr ite ria li st ed in

P ar t 1

th ro ug h

F ee l f re e to us e tw o lin es fo r a s in gl e ca se if y ou n ee d to

. Y ou m us t c om pl et e an

In ju ry a nd Il ln es s In ci de nt R ep or t ( O

Fo rm

) o r e qu iv al en t f or m fo r e ac h in ju ry o r i lln es s re co rd ed o n th is fo rm . I f y ou

’re n ot s ur e w he th er a c as e is re co rd ab le

, c al l y ou r l oc al O

A of fic e fo r h el p.

A tt e n ti o n :T hi s fo rm c on ta in s in fo rm at io n re la tin g to em pl oy ee h ea lth a nd m us t b e us ed in a m an ne r t ha t pr ot ec ts th e co nf id en tia lit y of e m pl oy ee s to th e ex te nt po ss ib le w hi le th e in fo rm at io n is b ei ng u se d fo r oc cu pa tio na l s af et y an d he al th p ur po se s.

X Y Z

C om pa n y

A n yw he re M

F o rm ap p ro ve d O

M B n o

-0

D e a th

D a ys a w a y fr o m w o rk J o b t ra n sf e r o r re st ri c ti o n

R e m a in e d a t W o rk

O th e r re c o rd a b le c a se s

A w a y fr o m w o rk

O n j o b tr a n sf e r o r re st ri c ti o n

E n te r th e n u m b e r o f d a ys t h e i n ju re…

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Nov 14, 2017.