A.01.29_Specifications_16R0003.pdf
PDF 3 MB Posted
- Attached to
- Rehabilitate & Paint Tainter Gates, Greers Ferry Dam, Little Red River, Cleburne County, AR
- Solicitation number
- W9127S-16-R-0003
About this file
Specifications
View the file
Other files
| File | Type | Posted |
|---|---|---|
| A.07.24_Amendment_0002_16R0003.pdf | ||
| A.07.24_Amendment_0001_16R0003.pdf | ||
| A.01.13_Plans_16R0003.pdf | ||
| A.07.23_Solicitation_16R0003.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
US Army Corps of Engineers Little Rock District SPECIFICATIONS
REHABILITATE AND PAINT TAINTER
GATES
GREERS FERRY DAM
LITTLE RED RIVER
CLEBURNE COUNTY, ARKANSAS
PN336755
JUNE 2016
SOLICITATION NO. W9127S-16-R-0003
Rehabilitate and Paint Tainter Gates Greers Ferry Dam Little Red River Cleburne County, Arkansas
SECTION B
BIDDING SCHEDULE
(To be attached to SF 1442)
SOLICITATION NUMBER W9127S-16-R-0003
Line
Item
No.
Description Estimated
Quantity
Unit
Measure Unit Price Amount
BASE BID
0001 Rehabilitate and Paint Tainter Gates 1 and 2 1 Job XXX $__________
0002 FCM Inspection Gates 1 and 2 1 Job XXX $__________
TOTAL BASE BID $__________
OPTIONS
Option 1
0003 Rehabilitate and Paint Tainter Gate 3 1 Job XXX $__________
Option 2
0004 FCM Inspection Gate 3 1 Job XXX $__________
Option 3
0005 Rehabilitate and Paint Tainter Gate 4 1 Job XXX $__________
Option 4
0006 FCM Inspection Gate 4 1 Job XXX $__________
Option 5
0007 Rehabilitate and Paint Tainter Gate 5 1 Job XXX $__________
Option 6
0008 FCM Inspection Gate 5 1 Job XXX $__________
Option 7
0009 Rehabilitate and Paint Tainter Gate 6 1 Job XXX $__________
Option 8
0010 FCM Inspection Gate 6 1 Job XXX $__________
Option 9
0011 Paint Catwalk and Machinery Platforms 1 Job XXX $__________
Rehabilitate and Paint Tainter Gates Greers Ferry Dam Little Red River Cleburne County, Arkansas
SECTION B
BIDDING SCHEDULE
(To be attached to SF 1442)
SOLICITATION NUMBER W9127S-16-R-0003
Option 10
0012 Repair Catwalk and Machinery Platforms 1 Job XXX $__________
Option 11
0013 Bird Protection 1 Job XXX $__________
Option 12
0014 Flood Demobilization/Remobilization 1 Each $_________ $__________
Option 13
0015 Spillway Access Platforms and Ladders 1 Each $__________ $__________
TOTAL BASE BID PLUS OPTIONS $___________
PROJECT TABLE OF CONTENTS
DIVISION 01 - GENERAL REQUIREMENTS
01 00 50 FORMS AND ATTACHMENTS
01 11 00 SUMMARY OF WORK
01 14 00.10 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 13.01 10 SPECIAL PROJECT PROCEDURES - FLOOD CONTROL
01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS
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
DIVISION 02 - EXISTING CONDITIONS
02 83 13.00 20 LEAD IN CONSTRUCTION
DIVISION 05 - METALS
05 05 23.16 STRUCTURAL WELDING
05 05 24.10 SIDE AND BOTTOM SEAL ASSEMBLIES
05 50 13 MISCELLANEOUS METAL FABRICATIONS
05 52 00 METAL RAILINGS
DIVISION 09 - FINISHES
09 97 02 PAINTING: HYDRAULIC STRUCTURES
DIVISION 26 - ELECTRICAL
26 42 14.00 10 CATHODIC PROTECTION SYSTEM (SACRIFICIAL ANODE)
-- End of Project Table of Contents --
PROJECT TABLE OF CONTENTS Page 1
THIS PAGE INTENTIONALLY LEFT BLANK
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
See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS
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 USACE-LITTLE ROCK DISTRICT NATIONAL BACKGROUND SCREENING
CONSENT/RELEASE FORM (SSCI-2013)
See Section 01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS
1.11 OPTIONAL FORM 306
See Section 01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS
1.12 SWL Form 487 USACE-SWL CONTRACTOR REQUIRED INFORMATION FORM
See Section 01 15 10.10 46 AT/OPSEC SITE SECURITY REQUIREMENTS
SECTION 01 00 50 Page 1
PART 2 PRODUCTS
Not Used.
PART 3 EXECUTION
Not Used
-- End of Section --
SECTION 01 00 50 Page 2
S U
B M
IT
T
A L
F O
R M
,J a n
P
R E
V
IO
U S
E D
IT
IO
N I
S O
B S
O L
E T
E P
A G
E
O F
P
A G
E S
R e h a b ili ta te a n d P a in t T a in te r
G a te s
.1
S D
-0
P re c o n s tr u c ti o n
S u b m it ta ls
.1
.1 G
C ra n e l o a d in g o n s p ill w a y b ri d g e
.1
.1 G
W o rk p la tf o rm s a n d a n c h o ra g e
.9
.3 G
W o rk A re a
L a y o u t
P la n
.1
.1 G
L a y o u t
F o r B a rg e s
A n d F lo a ti n g
P la tf o rm s
.1
G
T ra ff ic
C o n tr o l
P la n
S D
-0
P ro d u c t
D a ta
G P a tc h in g M a te ri a l fo r w o rk p la tf o rm A n c h o r H o le s
.0
S D
-0
P re c o n s tr u c ti o n
S u b m it ta ls
G C o n s tr u c ti o n P ro g re s s C h a rt
S D
-0
C e rt if ic a te s
M o n th ly U p d a te s
S D
-0
P re c o n s tr u c ti o n
S u b m it ta ls
.1
G
S u b m it ta l R e g is te r
.0
S D
-0
P re c o n s tr u c ti o n
S u b m it ta ls
.2
.3 G
G a te A c c e s s P la n
S D
-0
P re c o n s tr u c ti o n
S u b m it ta ls
.6
G A c c id e n t
P re v e n ti o n
P la n
A P
P
.7
G A c ti v it y H a z a rd
A n a ly s is
A
H A
.6
.1 G
C ra n e
C ri ti c a l
L if t P la n
.5
.1 .2
G C ra n e O p e ra to rs
S D
-0
T e s t
R e p o rt s
.1
N o ti fi c a ti o n s a n d
R e p o rt s
.1
.2
G A c c id e n t
R e p o rt s
S U B M
IT
T A L R E G
IS
T E R
C O
N T
R A
C T
N O
T
IT
L E
A N
D L
O C
A T
IO
N
C O
N T
R A
C T
O R
C O
N T
R A
C T
O R
S
C H
E D
U L
E D
A T
E S
C O
N T
R A
C T
O R
A C
T
IO
N A
P P
R O
V
IN
G A
U T
H O
R
IT
Y
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
R
IP
T
IO
N
IT
E
M S
U B
M
IT
T E
D
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
M
IT
A P
P R
O V
A L
N E
E D
E D
B Y
M A
T E
R
IA
L N
E E
D E
D B
Y
A C T I O N C O D E
D A
T E
O F
A C
T
IO
N
D A
T E
F W
D T
O A
P P
R A
U T
H
D A
T E
R C
D F
R O
M C
O N
T R
D A
T E
F W
D T
O O
T H
E R
R E
V
IE
W E
R
D A
T E
R C
D F
R O
M O
T H
R E
V
IE
W E
R
A C T I O N C O D E
D A
T E
O F
A C
T
IO
N
M A
IL
E
D T
O C
O N
T R
D A
T E
R C
D F
R M
A P
P R
A U
T H
R E
M A
R K
S
(a
(b
(c
(d
(e
(f
(g
(h
(i
(j
(k
(l
(m
(n
(o
(p
(q
(r
B M
IT
T
A L
F O
R M
,J a n
P
R E
V
IO
U S
E D
IT
IO
N I
S O
B S
O L
E T
E P
A G
E
O F
P
A G
E S
R e h a b ili ta te a n d P a in t T a in te r
G a te s
.1
.3
C ra n e
R e p o rt s
S D
-0
C e rt if ic a te s
.8
C o n fi n e d S p a c e
E n tr y
P e rm it
.8
H o t w o rk p e rm it
L ic e n s e
C e rt if ic a te s
.0
S D
-0
P re c o n s tr u c ti o n
S u b m it ta ls
.2
G C o n tr a c to r Q u a lit y
C o n tr o l
(C Q
C
P la n
S D
-1
C lo s e o u t S u b m it ta ls
.2
.1 R e c o rd
D ra w in g s
.0
S D
-0
P re c o n s tr u c ti o n
S u b m it ta ls
.5
.2 .2
G L e a d C o m p lia n c e P la n
.5
.1 .1
C o m p e te n t
P e rs o n
.5
.1 .2
T ra in in g C e rt if ic a ti o n
.5
.2 .8
G le a d w a s te m a n a g e m e n t p la n
.5
.2 .4
G M e d ic a l E x a m in a ti o n s
S D
-0
T e s t
R e p o rt s
.5
.2 .3
G s a m p lin g r e s u lt s
.5
.2 .3
O c c u p a ti o n a l a n d
E n v ir o n m e n ta l
A s s e s s m e n t
D a ta R e p o rt
S D
-0
C e rt if ic a te s
.5
.1 .3
G T e s ti n g l a b o ra to ry
.5
.1 .4
G T h ir d p a rt y c o n s u lt a n t q u a lif ic a ti o n s
.5
.1 .1
G C le a ra n c e
C e rt if ic a ti o n
S D
-1
C lo s e o u t S u b m it ta lsS U B M
IT
T A L R E G
IS
T E R
C O
N T
R A
C T
N O
T
IT
L E
A N
D L
O C
A T
IO
N
C O
N T
R A
C T
O R
C O
N T
R A
C T
O R
S
C H
E D
U L
E D
A T
E S
C O
N T
R A
C T
O R
A C
T
IO
N A
P P
R O
V
IN
G A
U T
H O
R
IT
Y
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
R
IP
T
IO
N
IT
E
M S
U B
M
IT
T E
D
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
M
IT
A P
P R
O V
A L
N E
E D
E D
B Y
M A
T E
R
IA
L N
E E
D E
D B
Y
A C T I O N C O D E
D A
T E
O F
A C
T
IO
N
D A
T E
F W
D T
O A
P P
R A
U T
H
D A
T E
R C
D F
R O
M C
O N
T R
D A
T E
F W
D T
O O
T H
E R
R E
V
IE
W E
R
D A
T E
R C
D F
R O
M O
T H
R E
V
IE
W E
R
A C T I O N C O D E
D A
T E
O F
A C
T
IO
N
M A
IL
E
D T
O C
O N
T R
D A
T E
R C
D F
R M
A P
P R
A U
T H
R E
M A
R K
S
(a
(b
(c
(d
(e
(f
(g
(h
(i
(j
(k
(l
(m
(n
(o
(p
(q
B M
IT
T
A L
F O
R M
,J a n
P
R E
V
IO
U S
E D
IT
IO
N I
S O
B S
O L
E T
E P
A G
E
O F
P
A G
E S
R e h a b ili ta te a n d P a in t T a in te r
G a te s
.0
.5
.2 .1
G h a z a rd o u s w a s te m a n if e s t
.5
.2 .1
G tu rn -i n d o c u m e n ts o r w e ig h t ti c k e ts
.1
S D
-0
P re c o n s tr u c ti o n
S u b m it ta ls
.2
W e ld in g Q u a lit y
A s s u ra n c e
P la n
.3
.2 G
D is to rt io n
M it ig a ti o n P la n
S D
-0
P ro d u c t
D a ta
.3
G W e ld in g
P ro c e d u re Q u a lif ic a ti o n s
.3
.6 W e ld e r, W e ld in g O p e ra to r, a n d
T a c k e r
Q u a lif ic a ti o n
.3
.7 In s p e c to r
Q u a lif ic a ti o n
.3
.3 P re v io u s Q u a lif ic a ti o n s
.3
.4 P re -Q u a lif ie d P ro c e d u re s
.2
W e ld in g E le c tr o d e s a n d
R o d s
S D
-0
T e s t
R e p o rt s
.3
N o n d e s tr u c ti v e
T e s ti n g
S D
-0
C e rt if ic a te s
.3
.1 G
C e rt if ie d
W e ld in g P ro c e d u re
S p e c if ic a ti o n s
W P
S
.3
.1 C e rt if ie d B ra z in g
P ro c e d u re
S p e c if ic a ti o n s
B P
S
.3
.1 C e rt if ie d P ro c e d u re
Q u a lif ic a ti o n
R e c o rd s
P
Q R
.3
.1 C e rt if ie d W e ld e r
P e rf o rm a n c e
Q u a lif ic a ti o n s
W
P Q
S U B M
IT
T A L R E G
IS
T E R
C O
N T
R A
C T
N O
T
IT
L E
A N
D L
O C
A T
IO
N
C O
N T
R A
C T
O R
C O
N T
R A
C T
O R
S
C H
E D
U L
E D
A T
E S
C O
N T
R A
C T
O R
A C
T
IO
N A
P P
R O
V
IN
G A
U T
H O
R
IT
Y
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
R
IP
T
IO
N
IT
E
M S
U B
M
IT
T E
D
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
M
IT
A P
P R
O V
A L
N E
E D
E D
B Y
M A
T E
R
IA
L N
E E
D E
D B
Y
A C T I O N C O D E
D A
T E
O F
A C
T
IO
N
D A
T E
F W
D T
O A
P P
R A
U T
H
D A
T E
R C
D F
R O
M C
O N
T R
D A
T E
F W
D T
O O
T H
E R
R E
V
IE
W E
R
D A
T E
R C
D F
R O
M O
T H
R E
V
IE
W E
R
A C T I O N C O D E
D A
T E
O F
A C
T
IO
N
M A
IL
E
D T
O C
O N
T R
D A
T E
R C
D F
R M
A P
P R
A U
T H
R E
M A
R K
S
(a
(b
(c
(d
(e
(f
(g
(h
(i
(j
(k
(l
(m
(n
(o
(p
(q
H
EE
T
O
F
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
EC
K O
N E:
T H
IS
I S A
N
EW
T R A
N S M
IT
T A
L T H
IS
I S A
R
ES
U B M
IT
T A
L
R A
N S M
IT
T A
L
D A
T E
R
EM
A R K S
C O
N T R A
C T R
EF
ER
EN
C
E D
O C
U M
EN
T
S
PE
C
IF
IC
A
T
IO
N S
EC
N
O
(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
FR
O M
PR
O
JE
C
T T
IT
LE
A N
D L
O C
A T
IO
N
C O
N T R A
C T N
O
EN
C
LO
S U
R
ES
R
ET
U R N
ED
Li st b y It em
N o.
T R A
N S M
IT
T A
L O
F S H
O P
D R A
W
IN
G S
EQ
U
IP
M
EN
T D
A T A
M
A T
ER
IA
L
S A
M
PL
ES
O
R M
A N
U
FA
C T U
R
ER
'S C
ER
T
IF
IC
A
T
ES
O F
C O
M
PL
IA
N
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
S
EC
T
IO
N I R
EQ
U
ES
T F
O R A
PP
R O
V A
L O
F T H
E
FO
LL
O
W
IN
G
IT
EM
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
IT
T A
L N
N A
M E, T
IT
LE
A
N D
S
IG
N A
T U
R E
O F
A
PP
R O
V
IN
G A
U T H
O R
IT
Y D
A T E
S
EC
T
IO
N I I A
PP
R O
V A
L A
C T
IO
N
IT
EM
N O a.
D
ES
C R
IP
T
IO
N O
F
IT
EM
S
U B M
IT
T
ED
(T yp e si ze m od el n um be r/ et c.
b.
M
FG
O R C
O N
T R
C A
T
C U
R V
E D
R A
W
IN
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
O
F C
O
PI
ES
d.
S
PE
C
PA
R A
N
O e.
D R A
W
IN
G S H
EE
T N
O f.
FO
C
N T R A
C T O
R U
S E
C O
D E g.
V A
R
IA
T
IO
N (S ee in st ru ct io n N o.
h.
FO
R
C E
U S E
C O
D E i.
N A
M E
A N
D S
IG
N
A T U
R E
O F
C O
N T R A
C T O
R
EN
G
F O
R M
-R
M
A R
(P ro po ne nt
C
EM
P-
C E)
ED
IT
IO
N
O F
S
EP
I S O
B S O
LE
T E.
(E R
-1
-1
C H
EC
K
O N
E:
T
H
IS
T R A
N S M
IT
T A
L
IS
FO
IO
G
V 'T
A
PP
R O
V
L
IN
T R U
C T
IO
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
I
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.
he
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
E
FO
LL
O
W
IN
G A
C T
IO
N C
O D
ES
A
R E
G
IV
EN
T
O I T
EM
S S
U B M
IT
T
ED
A
A pp ro ve d as s ub m it te d.
B
A pp ro ve d, e xc ep t as n ot ed o n dr aw in gs
C
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.
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
EN
G
F or m
-R
E
D is ap pr ov ed
S ee a tt ac he d)
F
R ec ei pt a ck no w le dg ed
FX
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
G
O th er
S pe ci fy
T
IV
IT
Y
H A
Z A
R D
A N
A L
Y
SI
N T
R A
C T
N O
PR
O
JE
D
E
L
C A
T
IO
N
ST
IM
A T
E D
S T
A R
T D
A
PR
C
IP
A L
S T
PS
PO
E
N T
IA
L
S A
FE
T
Y /H
E A
L T
H H
A
ZA
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 d
Q
U
IP
M E
N T
T O
B E
U
SE
SP
E C
T
IO
N R
E Q
U
IR
E M
E N
T S
T R
A
IN
IN
G
R E
Q U
IR
E
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)
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 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
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
L og
L og
L og
S u m m ar y.
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
(5
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
(6
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 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
.3
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
S u m m ar y
L og
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
C
F R
P ar t
.5
(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 R
.7
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
H
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 S
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 d en 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
SH
) 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.
O
SH
A’ s re co rd ke ep in g re gu la tio n
(s ee
C
FR
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 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
IV
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 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
A
ID
S H
IV
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:
E xa m p le s:
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
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
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
(H
(I an d
(J
(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
A
(c
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)
,0
N u m be r of ho u rs w or ke d by al l em pl oy ee s
D
A R
T in ci de n ce ra te
X
X
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
X
,0
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
X
,0 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
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
N
LY
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
R
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
(A
B
(F
(G
I)
J)
(K
L)
(1
(2
3)
(4
5)
6)
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
C
FR
P ar t 1
4.
th ro ug h
.1
2.
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
SH
A
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
SH
A of fic e fo r h el p.
(M
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
A
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 d o r il l w o rk e r w a s:
C H
E C
K O
N
LY
O N
E b o x f o r e a c h c a se b a se d o n t h e m o st s e ri o u s o u tc o m e f o r th a t c a se
(R ev
. 0 1/
.S
D e p a rt m e n t o f
L a b o r O c c u p a ti o n a l
S a fe…
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 .