A.01.29_Specs.pdf

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Attached to: Rehabilitate Station Service Unit Draft Tube Gates
Solicitation number: W9127S-17-R-0004
Issued by: Department of the Army Corps of Engineers Engineering District Little Rock

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US Army Corps of Engineers Little Rock District SPECIFICATIONS

REHABILITATE STATION SERVICICE UNIT

DRAFT TUBE GATES

BULL SHOALS DAM

WHITE RIVER

BAXTER COUNTY, ARKANSAS

PN# 462737

SOLICITATION

JULY 2017

SOLICITATION NO. W9127S-17-R-0004

Rehabilitate Station Service Unit Draft Tube Gates Bull Shoals Dam,White River, Baxter County, Arkansas

SECTION B

BIDDING SCHEDULE

(To be attached to SF 1442)

SOLICITATION NUMBER W9127S-17-R-0004

Line Item No.

Description Estimated Quantity

Unit Measure

Unit Price Amount

BASE BID

0001 Bulkhead 1 Job XXX $__________

0002 Bulkhead Deck and Apurtenances 1 Job XXX $__________

0003 Unit A and B Draft Tube Gate Actuators 1 Job XXX $__________

0004 Unit A Draft Tube Gate: Gate, Stem, Stem Guides, and Frame

1 Job XXX $__________

0005 Transportation, Services, Equipment Rental, and Parts and Materials

4 Each NOT TO EXCEED $24,000

0006 Flood Demobilization/Remobilization 2 Each $__________ $__________

TOTAL BASE BID $__________

OPTIONS

Option 1

0007 Unit B Draft Tube Gate: Rehabilitation 1 Job XXX $__________

Option 2

0008 Unit A Draft Tube Gate Frame Connection: 60" Diameter Pipe Flange

1 Job XXX $__________

TOTAL BASE BID PLUS OPTIONS $___________

THIS PAGE INTENTIONALLY LEFT BLANK

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 13.01 10 SPECIAL PROJECT PROCEDURES - FLOOD CONTROL

01 35 13.11 10 SPECIAL PROJECT PROCEDURES - MARINE WORK

01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

01 45 00.00 10 QUALITY CONTROL

01 45 00.15 10 RESIDENT MANAGEMENT SYSTEM CONTRACTOR MODE(RMS CM)

01 57 19 TEMPORARY ENVIRONMENTAL CONTROLS

01 78 00 CLOSEOUT SUBMITTALS

01 78 23 OPERATION AND MAINTENANCE DATA

DIVISION 03 - CONCRETE

03 30 53 MISCELLANEOUS CAST-IN-PLACE CONCRETE

DIVISION 05 - METALS

05 50 13 MISCELLANEOUS METAL FABRICATIONS

05 51 33 METAL LADDERS

05 52 00 METAL RAILINGS

05 59 13 FABRICATION OF HYDRAULIC STEEL STRUCTURES

DIVISION 09 - FINISHES

09 97 02 PAINTING: HYDRAULIC STRUCTURES

DIVISION 26 - ELECTRICAL

26 00 00.00 20 BASIC ELECTRICAL MATERIALS AND METHODS

26 20 00 INTERIOR DISTRIBUTION SYSTEM

DIVISION 33 - UTILITIES

33 49 33.00 03 SLUICE (SLIDE) GATES

DIVISION 41 - MATERIAL PROCESSING AND HANDLING EQUIPMENT

41 22 23.19 MONORAIL HOISTS

-- End of Project Table of Contents --

PROJECT TABLE OF CONTENTS Page 1

W9127S-17-R-0004

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

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G P h a s in g P la n

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S D -0 S h o p D ra w in g s

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A ir -E n tr a in in g A d m ix tu re

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(W P S

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M a te ri a ls D is p o s it io n R e c o rd

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W it n e s s P o in ts

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Q u a lif ic a ti o n o f W e ld e rs a n d

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T A L R E G

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B S R e h a b S ta ti o n S e rv ic e U n it D ra ft T u b e G a te s a n d O p e ra to rs

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G D O

In s p e c to r Q u a lif ic a ti o n s

.4 .3

G D O

Q u a lif ic a ti o n o f S tr u c tu ra l S te e l

F a b ri c a to r

S D -0 M a n u fa c tu re r’ s F ie ld

R e p o rt s

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G D O

C o n tr o l D im e n s io n s

S D -0 P re c o n s tr u c ti o n S u b m it ta ls

S a fe ty H e a lt h a n d

E n v ir o n m e n ta l R e q u ir e m e n ts

G (i f re q u ir e d

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G S O

S a fe ty P la n

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G S O

C o n fi n e d S p a c e s P la n

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G S O

R e s p ir a to ry P ro te c ti o n P la n

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A ir b o rn e S a m p lin g P la n

G S O

.2 .1

G S O

V e n ti la ti o n A s s e s s m e n t P la n

.2 .2

G S O

M e d ic a l S u rv e ill a n c e P la n

.2 .2 .2

G S O

W o rk e r P ro te c ti o n P la n

.2 .3

E n v ir o n m e n ta l P ro te c ti o n P la n

.2 .3 .1

W a s te M a n if e s t

.2 .3 .1

W a s te D is p o s a l P la n

.2 .3 .2

G A O

C o n ta in m e n t P la n

.2 .3 .3

G A O

V is ib le E m is s io n s M o n it o ri n g P la n

G A O

P M -1 M o n it o ri n g P la n

.2 .3 .4

G A O

T S P M o n it o ri n g P la n

.2 .3 .5

G A O

W a te r Q u a lit y P la n

S U B M

T A L R E G

T E R

C O N T R A C T N O

L E A N D L O C A T

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

A P P R O V

G A U T H 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 R

E M S U B M

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

A P P R O V A L

N E E D E D

B Y

M A T E R

N E E D E D

B Y

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D A T E

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D A T E R C D

F R O M O T H

R E V

W E R

A C T I O N C O D E

D A T E

O F

A C T

M A

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

B M

T A L F O R M ,J a n

P R E V

U S E D

N I S O B S O L E T E

P A G E O F P A G E S

B S R e h a b S ta ti o n S e rv ic e U n it D ra ft T u b e G a te s a n d O p e ra to rs

.2 .3 .6

G A O

S o il Q u a lit y P la n

S D -0 P ro d u c t D a ta

P a rt

G D O

M a n u fa c tu re r' s P ro d u c t D a ta

S h e e t

S D -0 S a m p le s

P a rt

G P ro d u c t S a m p le s

G D O

S p e c ia l P a in t F o rm u la s

.3 .3

G D O

S o lv e n t a n d T h in n e rs

S D -0 T e s t R e p o rt s

.2 .3 .4

T S P T e s t R e p o rt

.2 .3 .6

S o il Q u a lit y T e s t R e p o rt

In s p e c ti o n R e p o rt s

.2 .2 .2

M e d ic a l S ta tu s R e p o rt

.2 .2 .3

C h a n g e i n M e d ic a l S ta tu s R e p o rt

.2 .2 .1

G A O

A ir M o n it o ri n g T e s t P la n

.2 .2 .1

A ir M o n it o ri n g T e s t R e p o rt

S D -0 C e rt if ic a te s

.4 .1

C e rt if ie d E H S P ro fe s s io n a l

.4 .2

C e rt if ie d L e a d L a b o ra to ry

.4 .3

S S P C Q P C e rt if ic a te

.4 .5

C o a ti n g T h ic k n e s s G a g e

Q u a lif ic a ti o n

.4 .4

G D O

Q u a lif ie d P a in t A p p lic a to r

S D -0 S h o p D ra w in g s

G W ir e w a y s

G L o a d c e n te rs f o r h o u s in g u n it s

S U B M

T A L R E G

T E R

C O N T R A C T N O

L E A N D L O C A T

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

A P P R O V

G A U T H 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 R

E M S U B M

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

A P P R O V A L

N E E D E D

B Y

M A T E R

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

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

W E R

D A T E R C D

F R O M O T H

R E V

W E R

A C T I O N C O D E

D A T E

O F

A C T

M A

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

B M

T A L F O R M ,J a n

P R E V

U S E D

N I S O B S O L E T E

P A G E O F P A G E S

B S R e h a b S ta ti o n S e rv ic e U n it D ra ft T u b e G a te s a n d O p e ra to rs

.1 .4 .1

G M a rk in g s tr ip s

S D -0 P ro d u c t D a ta

.7 .1

G C ir c u it b re a k e rs

G T ra n s fo rm e rs

G E n c lo s e d c ir c u it b re a k e rs

G M a n u a l m o to r s ta rt e rs

S D -0 T e s t R e p o rt s

.5 .2

G -v o lt w ir in g t e s t

G G ro u n d in g s y s te m t e s t

.5 .3

G T ra n s fo rm e r te s ts

S D -0 M a n u fa c tu re r’ s F ie ld

R e p o rt s

.1 .1

T ra n s fo rm e r fa c to ry t e s ts

S D -1 O p e ra ti o n a n d M a in te n a n c e

D a ta

.5 .1

G E le c tr ic a l S y s te m s

.0 S D -0 S h o p D ra w in g s

G S lu ic e G a te s

S D -0 P ro d u c t D a ta

G S lu ic e G a te s

G P e d e s ta l S u p p o rt S ta n d s

G W a rr a n ty

S D -0 D e s ig n D a ta

G G a te S te m a n d P e d e s ta l (l if t)

G E le c tr ic A c tu a to r

S U B M

T A L R E G

T E R

C O N T R A C T N O

L E A N D L O C A T

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

A P P R O V

G A U T H 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 R

E M S U B M

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

A P P R O V A L

N E E D E D

B Y

M A T E R

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

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

W E R

D A T E R C D

F R O M O T H

R E V

W E R

A C T I O N C O D E

D A T E

O F

A C T

M A

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

B M

T A L F O R M ,J a n

P R E V

U S E D

N I S O B S O L E T E

P A G E O F P A G E S

B S R e h a b S ta ti o n S e rv ic e U n it D ra ft T u b e G a te s a n d O p e ra to rs

.0 S D -1 O p e ra ti o n a n d M a in te n a n c e

D a ta

G M a in te n a n c e A n d O p e ra ti n g

M a n u a ls

S D -0 P ro d u c t D a ta

G E le c tr ic W ir e R o p e H o is t

G T ro lle y

G P e n d a n t P u s h b u tt o n S ta ti o n

.4 .1

G H o o k P ro o f T e s t

M a n u fa c tu re r' s P u b lis h e d T a b le s

S D -0 T e s t R e p o rt s p e rc e n t R a te d L o a d t e s t

.3 .5

N o -L o a d T e s t

P o s t- E re c ti o n I n s p e c ti o n

O p e ra ti o n a l T e s ts

R a te d L o a d S p e e d T e s t

.4 .1

W ir e R o p e B re a k in g S tr e n g th

.8 .1

H o o k N D T R e p o rt

.3 .4

H o o k T ra m M e a s u re m e n t

S D -0 C e rt if ic a te s

.4 .1

C o m p lia n c e w it h a ll lis te d

S ta n d a rd s

.4 .1

S e m i- A n n u a l O v e rl o a d /S a fe f o r

T e s ti n g

.4 .1

B ra k e S e tt in g s

R u n w a y S tr a ig h tn e s s /L e v e ln e s s

S U B M

T A L R E G

T E R

C O N T R A C T N O

L E A N D L O C A T

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

A P P R O V

G A U T H 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 R

E M S U B M

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

A P P R O V A L

N E E D E D

B Y

M A T E R

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

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

W E R

D A T E R C D

F R O M O T H

R E V

W E R

A C T I O N C O D E

D A T E

O F

A C T

M A

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

B M

T A L F O R M ,J a n

P R E V

U S E D

N I S O B S O L E T E

P A G E O F P A G E S

B S R e h a b S ta ti o n S e rv ic e U n it D ra ft T u b e G a te s a n d O p e ra to rs

.4 .1

L o s s o f P o w e r T e s t

.4 .1

H o o k P ro o f T e s t

S D -1 O p e ra ti o n a n d M a in te n a n c e

D a ta

G H o is t s y s te m a ll c o m p o n e n ts

D a ta P a c k a g e

S U B M

T A L R E G

T E R

C O N T R A C T N O

L E A N D L O C A T

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

A P P R O V

G A U T H 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 R

E M S U B M

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

A P P R O V A L

N E E D E D

B Y

M A T E R

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

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

W E R

D A T E R C D

F R O M O T H

R E V

W E R

A C T I O N C O D E

D A T E

O F

A C T

M A

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

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

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

O N

T R A

N S M

T A

V 'T

R O

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

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)

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 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

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

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 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

F R

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

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

) 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 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 la ss if yi n g i ll n e ss e s

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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

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D h yp er se n si ti vi ty p n eu m o n…

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