A.01.29_Specifications_16R0012.pdf

US Army Corps of Engineers Little Rock District SPECIFICATIONS

FIELD OFFICE REPAIRS AND ADDITION

TOAD SUCK FERRY FIELD OFFICE

McCLELLAN-KERR ARKANSAS RIVER

NAVIGATION SYSTEM

FAULKNER COUNTY, ARKANSAS

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JUNE 2016

SOLICITATION NO. W9127S-16-R-0012

SECTION B

BIDDING SCHEDULE

(To be attached to SF 1442)

Line Item No.

Description Estimated Quantity

Unit Measure

Unit Price Amount

Renovate Existing Office Space And Construct A New Addition To The Existing Toad Suck Field Office Building And Incidental Related Work

1 Job XXX $__________

Overexcavate And Backfill Under New Foundation - One (1) Foot In Depth Measured From Bottom Of Adjacent Foundation Member For Entire New Building Addition and Atrium.

135 SY XXX $__________

TOTAL BASE BID $__________

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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 PRICE AND PAYMENT PROCEDURES

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 78 00 CLOSEOUT SUBMITTALS

01 78 23 OPERATION AND MAINTENANCE DATA

DIVISION 02 - EXISTING CONDITIONS

02 41 00 DEMOLITION

DIVISION 03 - CONCRETE

03 30 00 CAST-IN-PLACE CONCRETE

DIVISION 04 - MASONRY

04 20 00 UNIT MASONRY

DIVISION 06 - WOOD, PLASTICS, AND COMPOSITES

06 10 00 ROUGH CARPENTRY

06 20 00 FINISH CARPENTRY

DIVISION 07 - THERMAL AND MOISTURE PROTECTION

07 21 16 MINERAL FIBER BLANKET INSULATION

07 21 19 FOAMED-IN-PLACE INSULATION

07 31 13 ASPHALT SHINGLES

07 60 00 FLASHING AND SHEET METAL

07 92 00 JOINT SEALANTS

DIVISION 08 - OPENINGS

08 11 13 STEEL DOORS AND FRAMES

08 11 16 ALUMINUM DOORS AND FRAMES

08 14 00 WOOD DOORS

08 41 13 ALUMINUM-FRAMED ENTRANCES AND STOREFRONTS

08 51 13 ALUMINUM WINDOWS

08 71 00 DOOR HARDWARE

08 81 00 GLAZING

08 91 00 METAL WALL AND DOOR LOUVERS

DIVISION 09 - FINISHES

09 29 00 GYPSUM BOARD

09 30 10 CEMENT TILING, QUARRY TILING, AND PAVER TILING

09 65 00 RESILIENT FLOORING

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09 68 00 CARPETING

09 90 00 PAINTS AND COATINGS

DIVISION 23 - HEATING, VENTILATING, AND AIR CONDITIONING

23 00 00 AIR SUPPLY, DISTRIBUTION, VENTILATION, AND EXHAUST SYSTEMS

23 05 93 TESTING, ADJUSTING, AND BALANCING FOR HVAC

23 07 00 THERMAL INSULATION FOR MECHANICAL SYSTEMS

23 08 00.00 10 COMMISSIONING OF HVAC SYSTEMS

23 23 00 REFRIGERANT PIPING

23 82 01.00 10 WARM AIR HEATING SYSTEMS

23 82 02.00 10 UNITARY HEATING AND COOLING EQUIPMENT

DIVISION 26 - ELECTRICAL

26 20 00 INTERIOR DISTRIBUTION SYSTEM

26 51 00 INTERIOR LIGHTING

DIVISION 27 - COMMUNICATIONS

27 10 00 BUILDING TELECOMMUNICATIONS CABLING SYSTEM

DIVISION 28 - ELECTRONIC SAFETY AND SECURITY

28 20 99 INTRUSION DETECTION, ACCESS CONTROL, AND FIRE DETECTION

AND ALARM SYSTEM

DIVISION 31 - EARTHWORK

31 00 00 EARTHWORK

31 31 16.13 CHEMICAL TERMITE CONTROL

DIVISION 32 - EXTERIOR IMPROVEMENTS

32 16 13 CONCRETE SIDEWALKS AND CURBS AND GUTTERS

32 92 23 SODDING

DIVISION 33 - UTILITIES

33 11 23 NATURAL GAS AND LIQUID PETROLEUM PIPING

33 71 02 UNDERGROUND ELECTRICAL DISTRIBUTION

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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

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PART 2 PRODUCTS

Not Used.

PART 3 EXECUTION

Not Used

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01 33 00 SD-01 Preconstruction Submittals

1.10 GSubmittal Register

01 35 26 SD-01 Preconstruction Submittals

1.7 GAccident Prevention Plan (APP)

SD-06 Test Reports 1.4Monthly Exposure Reports 1.12Notifications and Reports

1.12.2 GAccident Reports

SD-07 Certificates 1.8Activity Hazard Analysis (AHA)

Certificate of Compliance License Certificates

01 45 00.00 10 SD-01 Preconstruction Submittals

3.2 GContractor Quality Control (CQC)

Plan 01 78 00 SD-03 Product Data

1.6.1Warranty Management Plan 1.6.5Warranty Tags

Spare Parts Data SD-08 Manufacturer’s Instructions

1.6.1Instructions SD-10 Operation and Maintenance Data

3.6 GOperation and Maintenance

Manuals

SD-11 Closeout Submittals

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01 78 00 3.1 GAs-Built Drawings

3.2.1 GRecord Drawings

3.3 GRecord Drawings

3.5As-Built Record of Equipment and Materials 3.4Final Approved Shop Drawings

Construction Contract Specifications

GCertification of EPA Designated Items

01 78 23 SD-10 Operation and Maintenance Data

1.3O&M Database 3.1.1Training Plan 3.1.3Training Outline 3.1.2Training Content

SD-11 Closeout Submittals Training Video Recording

3.1.5Validation of Training Completion 02 41 00 SD-01 Preconstruction Submittals

1.2.1Demolition Plan 03 30 00 SD-02 Shop Drawings

1.6.2.1 GReinforcing Steel

SD-05 Design Data

2.3.1 GMix Design

SD-06 Test Reports

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03 30 00 3.12.2.3 GCompressive Strength Tests 04 20 00 SD-02 Shop Drawings

3.4.1.1Detail Drawings SD-03 Product Data

1.5.1Hot Weather Procedures 1.5.2Cold Weather Procedures 2.1.2Clay Brick

SD-04 Samples 2.1.2Clay Brick

SD-05 Design Data Masonry Compressive Strength

SD-06 Test Reports 2.1.2.1.3Efflorescence Test

Field Testing of Mortar Field Testing of Grout

3.6.1.2Prism Tests SD-07 Certificates

2.1.2Clay Brick 2.3.1.4Admixtures for Masonry Mortar 2.3.2.2Admixtures for Grout 2.5.2Anchors, Ties, and Bar

Positioners 2.5.3Joint Reinforcement

06 10 00 SD-02 Shop Drawings

2.4.1 GTrussed rafters

SD-03 Product Data

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06 10 00 1.4.3Structural-use and OSB panels 2.3.1.1Structural-use and OSB panels 2.3Oriented Strand Board

SD-05 Design Data

2.4.1 GTrussed rafters

06 20 00 SD-02 Shop Drawings 1.3Detail Drawings

SD-04 Samples Siding Fascias and Trim

SD-07 Certificates 1.4Certificates of grade 1.4Certificates of compliance

07 21 16 SD-03 Product Data 2.1Blanket Insulation 2.2Sill Sealer Insulation 2.4Vapor Retarder

SD-08 Manufacturer’s Instructions 3.3.1Insulation

07 21 19 SD-06 Test Reports 2.2Closed-Cell Spray Polyurethane

Foam SD-07 Certificates

1.5.1 GInstaller Qualifications

SD-09 Manufacturer’s Field Reports

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07 21 19 2.2.1Spray Polyurethane Foam 07 31 13 SD-03 Product Data

2.1.1Shingles SD-04 Samples

2.1.1 GShingles

2.1.1 GColor charts

SD-08 Manufacturer’s Instructions 3.3Application

07 60 00 SD-02 Shop Drawings Covering on flat, sloped, or curved surfaces

3.1.10Gutters 3.1.11Downspouts 3.1.12Expansion joints

Gravel stops and fascias Base flashing

3.1.13Flashing at roof penetrations 3.1.9Drip edge

Eave flashing SD-11 Closeout Submittals

3.5Quality Control Plan 07 92 00 SD-03 Product Data

2.1Sealants 2.2Primers 2.3Bond breakers 2.4Backstops

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07 92 00 SD-07 Certificates 3.3.6Sealant

08 11 13 SD-02 Shop Drawings 2.1Doors 2.1Doors 2.4Frames 2.4Frames 2.2Accessories 2.5Weatherstripping

SD-03 Product Data 2.1Doors 2.4Frames 2.2Accessories 2.5Weatherstripping

08 11 16 SD-02 Shop Drawings 1.5.1Doors, windows and frames

SD-04 Samples 1.5.2.1Finish sample

SD-05 Design Data 1.2.1calculations

SD-08 Manufacturer’s Instructions 2.1Doors and frames

08 14 00 SD-02 Shop Drawings 2.1Doors

SD-03 Product Data 2.1Doors

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08 14 00 2.2Accessories 2.3.6Water-resistant sealer 1.4warranty

Sound transmission class rating Certification

SD-04 Samples 2.1Doors 2.3.5.1Door finish colors

08 41 13 SD-01 Preconstruction Submittals 1.2.1Sample Warranty 1.2.1Listing of Product Installations

SD-02 Shop Drawings 1.2.1Installation Drawings

1.2.1 GFabrication Drawings

SD-03 Product Data 1.2.1Manufacturer's Catalog Data

SD-04 Samples

1.2.1 GFinish and Color Samples

SD-06 Test Reports 1.2.1Certified Test Reports

SD-07 Certificates

3.4 GManufacturer's Product Warranty

08 51 13 SD-02 Shop Drawings 2.1Windows

Fabrication Drawings SD-03 Product Data

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08 51 13 2.1Windows 2.3Thermal-Barrier Windows 2.2.8Accessories 1.8.3Thermal Performance

SD-04 Samples Finish Sample Window Sample

SD-10 Operation and Maintenance Data

2.1Windows 08 71 00 SD-02 Shop Drawings

1.3Hardware schedule Keying system

SD-03 Product Data 2.3Hardware items

SD-08 Manufacturer’s Instructions 3.1Installation

SD-11 Closeout Submittals Key Bitting

08 81 00 SD-02 Shop Drawings Installation

SD-03 Product Data 1.5.1Insulating Glass 1.3Glazing Accessories

SD-04 Samples 1.5.1Insulating Glass

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08 81 00 2.3.2Glazing Compound 2.3.5Tape 2.3.3.1Sealant

SD-07 Certificates 1.5.1Insulating Glass

SD-08 Manufacturer’s Instructions 2.3Setting and Sealing Materials

08 91 00 SD-03 Product Data 2.2Metal Wall Louvers

09 29 00 SD-03 Product Data 2.1.3Cementitious backer units 2.1.2Glass Mat Covered or Reinforced

Gypsum Sheathing 2.1.7Accessories

Certification SD-07 Certificates

2.1Asbestos Free Materials SD-08 Manufacturer’s Instructions Material Safety Data Sheets

SD-10 Operation and Maintenance Data Manufacturer maintenance instructions

3.6Waste Management 09 30 10 SD-03 Product Data

2.1Tile

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09 30 10 2.2Setting-Bed 2.4Mortar, Grout, and Adhesive

SD-04 Samples 2.1Tile 2.4Grout

SD-07 Certificates 2.1Tile 2.4Mortar, Grout, and Adhesive

SD-08 Manufacturer’s Instructions 3.7Maintenance Instructions

SD-10 Operation and Maintenance Data

3.2Installation 09 65 00 SD-02 Shop Drawings

2.8Resilient Flooring and Accessories

SD-03 Product Data 2.8Resilient Flooring and

Accessories 2.4Adhesives

SD-04 Samples 2.8Resilient Flooring and

Accessories SD-06 Test Reports

3.3Moisture, Alkalinity and Bond Tests

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09 65 00 SD-08 Manufacturer’s Instructions 3.2Surface Preparation 3.1Installation

SD-10 Operation and Maintenance Data

2.8Resilient Flooring and Accessories

09 68 00 SD-03 Product Data 2.1Carpet 2.4Moldings

SD-04 Samples 2.1Carpet 2.4Moldings

SD-06 Test Reports 3.2Moisture and Alkalinity Tests

SD-07 Certificates 2.1Carpet 1.3Regulatory Requirements

SD-08 Manufacturer’s Instructions 3.1Surface Preparation 3.4Installation

SD-10 Operation and Maintenance Data

2.1Carpet 3.5Cleaning and Protection

Maintenance Service

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09 90 00 SD-03 Product Data Certification Manufacturer's Technical Data Sheets

Sealant 2.1Coating

SD-04 Samples GColor

Textured Wall Coating System Sample Textured Wall Coating System Mock-Up

SD-07 Certificates 1.3Applicator's qualifications 1.4.1.2Qualification Testing

SD-08 Manufacturer’s Instructions 1.7.2Manufacturer's Material Safety

Data Sheets 23 00 00 SD-02 Shop Drawings

1.4.5 GDetail Drawings

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23 00 00 Registers and Grilles Louvers Wall Heaters

SD-06 Test Reports

3.10 GPerformance Tests

SD-07 Certificates Certification

SD-08 Manufacturer’s Instructions 3.2Manufacturer's Installation

Instructions 3.11.2Operation and Maintenance

Training SD-10 Operation and Maintenance Data

3.11.1Operation and Maintenance Manuals

2.9.2Manual Balancing Dampers Automatic Control Damper Wall Heaters

23 05 93 SD-01 Preconstruction Submittals

1.5.3.1 GTAB Firm

1.2 GTAB Team Engineer

1.5.3.2 GTAB Specialist

1.2 GTAB Team Field Leader

SD-02 Shop Drawings

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23 05 93 1.3.2 GTAB Schematic Drawings and Report Forms

SD-03 Product Data

1.3 GEquipment and Performance

Data

1.5.3.4 GTAB Related HVAC Submittals

1.5.2 GTAB Procedures

1.5.2 GCalibration

1.3.2 GSystems Readiness Check

1.5.4 GTAB Execution

GTAB Verification SD-06 Test Reports

GCompleted Pre-Final DALT Report

3.3.5 GCertified Final DALT Report

1.6.1.1 GTAB Design Review Report

1.5.5.2 GTAB Report for Season 1

1.5.5.2 GTAB Report for Season 2

SD-07 Certificates

1.5.1 GIndependent TAB Agency and

Personnel Qualifications

1.6.1 GDALT and TAB Submittal and

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1.5.3.1 GTAB Firm

23 07 00 SD-02 Shop Drawings 3.2.2.4MICA Plates

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23 07 00 2.3Pipe Insulation Systems 3.2Pipe Insulation Systems 3.3Duct Insulation Systems

SD-03 Product Data 2.3Pipe Insulation Systems 3.2Pipe Insulation Systems 3.3Duct Insulation Systems

SD-04 Samples 2.2.1.3Thermal Insulation

SD-08 Manufacturer’s Instructions 2.3Pipe Insulation Systems 3.2Pipe Insulation Systems 3.3Duct Insulation Systems

23 08 00.00 10 SD-02 Shop Drawings

1.5.2.2 GCommissioning Plan

SD-03 Product Data

3.2.1 GPre-Functional Performance Test

Checklists

3.2.2 GFunctional Performance Tests

SD-06 Test Reports

3.3 GCommissioning Report

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1.5.1 GCommissioning Firm

1.5.2 GCommissioning Specialist

23 23 00 SD-02 Shop Drawings 2.3Refrigerant Piping System

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23 23 00 SD-03 Product Data 2.3Refrigerant Piping System

Spare Parts 1.3.1Qualifications 3.5Refrigerant Piping Tests 3.1Verification of Dimensions

SD-06 Test Reports 3.5Refrigerant Piping Tests

SD-10 Operation and Maintenance Data

1.5Maintenance 3.4Operation and Maintenance

Manuals 23 82 01.00 10 SD-02 Shop Drawings

3.2Installation SD-03 Product Data

1.6Spare Parts 3.6Tests

GSystem Diagrams 1.4Qualifications 3.5Field Training

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23 82 01.00 10 3.5Operating and Maintenance Manuals

23 82 02.00 10 SD-02 Shop Drawings 1.4Drawings

SD-03 Product Data 2.1Materials and Equipment 1.6Spare Parts 3.3Posted Instructions 3.5System Performance Tests

3.3 GDemonstrations

SD-06 Test Reports

3.4 GRefrigerant Tests, Charging, and

Start-Up

3.5 GSystem Performance Tests

SD-07 Certificates 2.1Materials and Equipment 2.1.1Service Organization

SD-10 Operation and Maintenance Data

3.3Operation and Maintenance Manuals

26 20 00 SD-02 Shop Drawings

2.12 G DOPanelboards

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2.11 G DOReceptacles

2.9 G DOSwitches

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26 20 00 2.14 G DOMotor controllers

2.15 G DOManual motor starters

G DOMetering

2.23 G DOMeter base only

2.18.3 G DOGrounding Busbar

2.24 G DOSurge protective devices

SD-06 Test Reports

3.5.2 G DO600-volt wiring test

3.5.5 G DOGrounding system test

3.5.4 G DOGround-fault receptacle test

SD-07 Certificates

2.10 G DOFuses

SD-10 Operation and Maintenance Data

G DOElectrical Systems G DOMetering

26 51 00 SD-03 Product Data G DOFluorescent lighting fixtures

2.5 G DOExit signs

2.6 G DOEmergency lighting equipment

2.7 G DOOccupancy sensors

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1.4.1Lighting Control System

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26 51 00 Operational Service 27 10 00 SD-02 Shop Drawings

1.6.1.1 G DOTelecommunications drawings

1.6.1.2 G DOTelecommunications Space

Drawings SD-03 Product Data

2.3 G DOTelecommunications cabling

2.5 G DOTelecommunications

outlet/connector assemblies

2.4.1 G DOEquipment support frame

2.4.2 G DOConnector blocks

1.10.3 G DOSpare Parts

SD-06 Test Reports

3.5.1 G DOTelecommunications cabling

testing SD-07 Certificates

1.6.2.1 G DOTelecommunications Contractor

1.6.2.2 G DOKey Personnel

1.6.2.3 G DOManufacturer Qualifications

1.6.3 G DOTest plan

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2.9.1 G DOFactory reel tests

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27 10 00 1.10.1 G DOTelecommunications cabling and pathway system

SD-11 Closeout Submittals

1.10.2 G DORecord Documentation

28 20 99 SD-02 Shop Drawings G DOSystem One-Line Diagram

SD-03 Product Data G DOIntrusion Detection System G DOAccess Control System G DOFire Detection and Alarm System G DOKey Control Plan

Spare Parts 3.1Manufacturer's Instructions

3.4.1 GTesting

Experience SD-06 Test Reports

3.4.2Performance Verification Test SD-07 Certificates Materials and Equipment

31 00 00 SD-01 Preconstruction Submittals

3.5 GShoring

1.3.3 GDewatering Work Plan

SD-03 Product Data 3.9Utilization of Excavated Materials 3.4Opening of any Excavation or

Borrow Pit

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31 00 00 SD-06 Test Reports 3.16Testing 2.1Borrow Site Testing

SD-07 Certificates 3.16Testing

31 31 16.13 SD-03 Product Data 3.3.6Termiticide Application Plan 2.1Termiticides 3.3.3Foundation Exterior 3.3.4Utilities and Vents 3.3.5Crawl and Plenum Air Spaces 3.1Verification of Measurement 3.4.1Application Equipment 1.6Warranty

SD-04 Samples 2.1Termiticides

SD-06 Test Reports 3.4.1Equipment Calibration and Tank

Measurement 1.5.1Soil Moisture 1.3Quality Assurance

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32 16 13 SD-03 Product Data 2.1Concrete

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32 16 13 3.8Field Quality Control 32 92 23 SD-03 Product Data

Fertilizer SD-06 Test Reports Topsoil composition tests

SD-07 Certificates 2.1sods

33 11 23 SD-03 Product Data 2.6Valve box 2.4.2Pressure regulator 2.5Gas equipment connectors 2.4Valves 2.7Warning and identification tape 2.2.3Risers 2.2.4Transition fittings

SD-07 Certificates 1.3.1Welder's qualifications 1.3.2PE welder's qualifications 1.3.1Welder's identification symbols

SD-08 Manufacturer’s Instructions 2.2.2PE pipe and fittings

33 71 02 SD-03 Product Data Conduit Sealing Material

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1.5.1 G DOCable Installer Qualifications

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ES

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ER

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ER

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IC

A

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ES

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IA

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(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

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IT

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

b.

M

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O R C

O N

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C U

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IN

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N O

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d.

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PA

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IN

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h.

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EN

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-R

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(P ro po ne nt

C

EM

P-

C E)

ED

IT

IO

N

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EP

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LE

T E.

(E R

-1

-1

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H

IS

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N S M

IT

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L

IS

FO

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G

V 'T

A

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V A

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PN 456018

Field Office Repairs and Addition

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

PN 456018

Field Office Repairs and Addition

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

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 ar 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)

PN 456018

Field Office Repairs and Addition

Field Office Repairs and Addition

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

PN 456018

Field Office Repairs and Addition 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

Field Office Repairs and Addition

ACCIDENT DESCRIPTION (Continuation)

DIRECT CAUSE (Continuation)

10.

13a.

Page 3 of 4 pages

PN 456018

Field Office Repairs and Addition

INDIRECT CAUSES (Continuation)

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

13b.

14.

Page 4 of 4 pages

PN 456018

Field Office Repairs and Addition

THIS PAGE INTENTIONALLY LEFT BLANK

Field Office Repairs and Addition

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

PN 456018

Field Office Repairs and Addition 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…