A.01.29_Specs.pdf

PDF 5 MB Posted Aug 15, 2018

Attached to: Dewatering Box Federal contract opportunity
Solicitation number: W9127S18Q0064
Issued by: Department of the Army Corps of Engineers Engineering District Little Rock

About this file

From the source

Specifications

View the file

Other files for this federal contract opportunity

Other files attached to Dewatering Box, newest first.
File	Type	Posted
Draft_RFP_UPDATED_21_AUG_18.pdf	PDF	Aug 21, 2018
A.01.13_Plans.pdf	PDF	Aug 15, 2018
Draft_RFP.pdf	PDF	Aug 15, 2018

On GovTribe

Work with this file on GovTribe

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

Try for free Login

Text version

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

US Army Corps of Engineers

Little Rock District SPECIFICATIONS

MKARNS-DEWATERING BOX

ORMOND LOCK AND DAM, NO. 8

McCLELLAN-KERR ARKANSAS RIVER

NAVIGATION SYSTEM

CONWAY COUNTY, ARKANSAS

PN457984

AUGUST 2018

SOLICITATION NO. W9127S-09-X-XXXX

Project Name Location, County, Arkansas

SECTION B

BIDDING SCHEDULE

(To be attached to SF 1442)

SOLICITATION NUMBER W9127S-X-X-0000

To edit heading: FILE / PAGE SETUP / CUSTOM HEADING To view heading: PRINT PREVIEW

Line Item No.

Description Estimated Quantity

Unit Measure

Unit Price Amount

BASE BID

0001 DEWATERING BOX 1 Lump Sum XXX $__________

TOTAL BASE BID $__________

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 22 00.00 10 PRICE AND PAYMENT PROCEDURES

01 32 01.00 10 PROJECT SCHEDULE

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 78 00 CLOSEOUT SUBMITTALS

DIVISION 05 - METALS

05 50 14 STRUCTURAL METAL FABRICATIONS

05 50 15 CIVIL WORKS FABRICATIONS

05 59 13 FABRICATION OF HYDRAULIC STEEL STRUCTURES

DIVISION 09 - FINISHES

09 97 02 PAINTING: HYDRAULIC STRUCTURES

DIVISION 35 - WATERWAY AND MARINE CONSTRUCTION

35 20 16.39 DEWATERING BOX

-- End of Project Table of Contents --

PROJECT TABLE OF CONTENTS Page 1

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

ORMOND LOCK AND DAM

CONWAY COUNTY, ARKANSAS SOLICITATION NO.

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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 SWL FORM 463

See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

1.5 OSHA FORM 300 & 301

See Section 01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

PART 2 PRODUCTS

Not Used.

PART 3 EXECUTION

Not Used

-- End of Section --

SECTION 01 00 50 Page 1

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

S U

B M

A L

F O

R M

,J a n

R E

U S

E D

N I

S O

B S

O L

E T

E P

A G

O F

A G

E S

M K

A R

N S

R e p a ir S to p lo g

C e n te rp o s t

R e c e iv e rs

S D

-0

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

P ro je c t

S c h e d u le r Q u a lif ic a ti o n s

.1 P re lim in a ry P ro je c t

S c h e d u le

.2 G

In it ia l P ro je c t

S c h e d u le

.2 P e ri o d ic

S c h e d u le

U p d a te

S D

-0

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

.1 G

C o n s tr u c ti o n P ro g re s s C h a rt

S D

-0

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

G S u b m it ta l R e g is te r

S D

-0

C e rt if ic a te s

.1 .6

C ra n e

O p e ra to rs

/R ig g e rs

.5 A c ti v it y H a z a rd A n a ly s is

H A

L ic e n s e

C e rt if ic a te s

.1 R a d io g ra p h y O p e ra ti o n P la n n in g

W o rk S h e e t

S D

-0

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

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

G A s -B u ilt

D ra w in g s

.1 G

R e c o rd D ra w in g s

G R e c o rd D ra w in g s

A s -B u ilt

R e c o rd o f E q u ip m e n t a n d M a te ri a ls

F in a l A p p ro v e d S h o p D ra w in g s

S U

B M

A L

R E

T E

R C

O N

T R

A C

T N

L E

A N

D L

O C

A T

C O

N T

R A

C T

O R

C O

N T

R A

C T

O R

C H

E D

U L

E D

A T

E S

C O

N T

R A

C T

O R

A C

N A

P P

R O

G A

U T

H O

A C T I V I T Y N O

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

S P E C S E C T

D E

S C

M S

U B

T E

P A R A G R A P H

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

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

U B

A P

P R

O V

A L

N E

E D

B Y

M A

T E

L N

E E

D E

D B

A C T I O N C O D E

D A

T E

O F

A C

D A

T E

F W

D T

O A

P P

R A

U T

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

W E

D A

T E

R C

D F

R O

M O

T H

R E

W E

A C T I O N C O D E

D A

T E

O F

A C

M A

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

B M

A L

F O

R M

,J a n

R E

U S

E D

N I

S O

B S

O L

E T

E P

A G

O F

A G

E S

M K

A R

N S

R e p a ir S to p lo g

C e n te rp o s t

R e c e iv e rs

C o n s tr u c ti o n C o n tr a c t

S p e c if ic a ti o n s

S D

-0

S h o p

D ra w in g s

.1 G

D e ta il

D ra w in g s

.2 .1

W e ld in g o f S tr u c tu ra l S te e l

.4 S tr u c tu ra l S te e l W e ld in g

R e p a ir s

S D

-0

P ro d u c t

D a ta

.2 .1

.3 .1

F ill e r

M e ta l

S D

-0

T e s t

R e p o rt s

T e s ts

In s p e c ti o n s a n d

V e ri fi c a ti o n s

S D

-0

C e rt if ic a te s

.2 W e ld in g

Q u a lif ic a ti o n s

S D

-0

S h o p

D ra w in g s

G M is c e lla n e o u s M e ta ls a n d

S ta n d a rd

M e ta l A rt ic le s

G S h o p F a b ri c a te d

M e ta l It e m s

S D

-0

P ro d u c t

D a ta

G M is c e lla n e o u s M e ta ls a n d

S ta n d a rd

M e ta l A rt ic le s

G S h o p F a b ri c a te d

M e ta l It e m s

S D

-0

T e s t

R e p o rt s

M is c e lla n e o u s M e ta ls a n d

S ta n d a rd

M e ta l A rt ic le s

S h o p

F a b ri c a te d

M e ta l It e m s

S D

-0

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

S U

B M

A L

R E

T E

R C

O N

T R

A C

T N

L E

A N

D L

O C

A T

C O

N T

R A

C T

O R

C O

N T

R A

C T

O R

C H

E D

U L

E D

A T

E S

C O

N T

R A

C T

O R

A C

N A

P P

R O

G A

U T

H O

A C T I V I T Y N O

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

S P E C S E C T

D E

S C

M S

U B

T E

P A R A G R A P H

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

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

U B

A P

P R

O V

A L

N E

E D

B Y

M A

T E

L N

E E

D E

D B

A C T I O N C O D E

D A

T E

O F

A C

D A

T E

F W

D T

O A

P P

R A

U T

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

W E

D A

T E

R C

D F

R O

M O

T H

R E

W E

A C T I O N C O D E

D A

T E

O F

A C

M A

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

B M

A L

F O

R M

,J a n

R E

U S

E D

N I

S O

B S

O L

E T

E P

A G

O F

A G

E S

M K

A R

N S

R e p a ir S to p lo g

C e n te rp o s t

R e c e iv e rs

.3 G

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

.4 .2

G F ra c tu re C o n tr o l P la n

C P

.1 G

W e ld T ra c k in g L o g

T e m p la te

S D

-0

S h o p

D ra w in g s

.5 G

S h o p

D ra w in g s

.7 G

W e ld in g R e p a ir s

N o n -F ra c tu re

C ri ti c a l M e m b e rs

.7 G

W e ld in g R e p a ir s

F ra c tu re

C ri ti c a l M e m b e rs

G D e liv e ry

/S h ip p in g

P la n

S D

-0

P ro d u c t

D a ta

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

S D

-0

T e s t

R e p o rt s

G C e rt if ie d T e s t

R e p o rt s

.2 G

W e ld T ra c k in g L o g

W it n e s s P o in ts

S D

-0

C e rt if ic a te s

G W o rk

P la n

.1 G

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

W e ld in g O p e ra to rs

.2 G

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

.3 G

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

S U

B M

A L

R E

T E

R C

O N

T R

A C

T N

L E

A N

D L

O C

A T

C O

N T

R A

C T

O R

C O

N T

R A

C T

O R

C H

E D

U L

E D

A T

E S

C O

N T

R A

C T

O R

A C

N A

P P

R O

G A

U T

H O

A C T I V I T Y N O

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

S P E C S E C T

D E

S C

M S

U B

T E

P A R A G R A P H

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

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

U B

A P

P R

O V

A L

N E

E D

B Y

M A

T E

L N

E E

D E

D B

A C T I O N C O D E

D A

T E

O F

A C

D A

T E

F W

D T

O A

P P

R A

U T

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

W E

D A

T E

R C

D F

R O

M O

T H

R E

W E

A C T I O N C O D E

D A

T E

O F

A C

M A

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

B M

A L

F O

R M

,J a n

R E

U S

E D

N I

S O

B S

O L

E T

E P

A G

O F

A G

E S

M K

A R

N S

R e p a ir S to p lo g

C e n te rp o s t

R e c e iv e rs

.8 G

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

G 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

.1 G

S a fe ty

P la n

.1 S

S P

C Q

C e rt if ic a te

.3 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

.2 G

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

.2 G

D e ta il

D ra w in g s

S D

-0

P ro d u c t

D a ta

M a te ri a ls

.2 G

W e ld in g

S D

-0

S a m p le s

G M a te ri a ls

.6 G

F a b ri c a ti o n s

S D

-0

T e s t

R e p o rt s

T e s ts

In s p e c ti o n s a n d

V e ri fi c a ti o n s

S U

B M

A L

R E

T E

R C

O N

T R

A C

T N

L E

A N

D L

O C

A T

C O

N T

R A

C T

O R

C O

N T

R A

C T

O R

C H

E D

U L

E D

A T

E S

C O

N T

R A

C T

O R

A C

N A

P P

R O

G A

U T

H O

A C T I V I T Y N O

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

S P E C S E C T

D E

S C

M S

U B

T E

P A R A G R A P H

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

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

U B

A P

P R

O V

A L

N E

E D

B Y

M A

T E

L N

E E

D E

D B

A C T I O N C O D E

D A

T E

O F

A C

D A

T E

F W

D T

O A

P P

R A

U T

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

W E

D A

T E

R C

D F

R O

M O

T H

R E

W E

A C T I O N C O D E

D A

T E

O F

A C

M A

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

V A

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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)

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

ACCIDENT DESCRIPTION (Continuation)

DIRECT CAUSE (Continuation)

10.

13a.

Page 3 of 4 pages

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

INDIRECT CAUSES (Continuation)

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

13b.

14.

Page 4 of 4 pages

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

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

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

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

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

C F

R P ar t

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

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

O S

H A fo r th es e ca se s.

In st ea d en te r

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

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

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

S H

A an d fo rm s.

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

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

L og

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

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

’s n a m e o n t h e

O S

H A

F o rm

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

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

C u t, p u n ct u re la ce ra ti o n ab ra si o n fr ac tu re b ru is e, am p u ta ti o n in se ct b it e, el ec tr o cu ti o n o r a th er m al ch em ic al el ec tr ic al o r ra d ia ti o n b u rn S p ra in an d st ra in in ju ri es to m u sc le s, jo in ts an d co n n ec ti ve ti ss u es ar e cl as si fi ed as in ju ri es w h en th ey re su lt fr o m a sl ip tr ip fa ll o r o th er si m il ar ac ci d en ts

E xa m p le s:

W h a t is f ir st a id

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

D o N

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

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

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

B an d A id s™ g au ze p ad s, et c.

o r u si n g S te ri

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

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

-r ig id b ac k b el ts et c.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

B eg in co u n ti n g d ay s fr o m th e d ay th e in ci d en t o cc u rs If a si n g le in ju ry o r il ln es s in vo lv ed b o th d ay s aw ay fr o m w o rk an d d ay s o f re st ri ct ed w o rk ac ti vi ty en te r th e to ta l n u m b er o f d ay s fo r ea ch Y o u m ay st o p co u n ti n g d ay s o f re st ri ct ed w o rk ac ti vi ty o r d ay s aw ay fr o m w o rk o n ce th e to ta l o f ei th er o r th e co m b in at io n o f b o th re ac h es d ay s.

af te r

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

S H

h ep at it is

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

m al ig n an t o r

E xa m p le s:

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

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

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

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

E xa m p le s:

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

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

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

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

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

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

S u m m a ry

H o w l o n g m u st y o u k e e p t h e L o g a n d S u m m a ry o n f il e

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

S H

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

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

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

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

A p ri l o f th at ye ar

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

N o

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

O S

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

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

S u m m ar y

L og

S u m m ar y

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

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

S H

A o ff ic e

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

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

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

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

-t im e w o rk er s

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

(u su al ly o n e ye ar

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

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

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

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

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

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

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

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

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

O S

H A

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

S H

A F o rm

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

(I an d

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

O S

H A

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

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

(H o n th e

O S

H A

F o rm

R ef er to O

S H

A F o rm

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

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

(T h e

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

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

(D A

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

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

(I o n

F o rm

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

(c o lu m n (M

-2 o n

F o rm

A et c.

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

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

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

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

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

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

B L

S R eg io n al

O ff ic e.

an d

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

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

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

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

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

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

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

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

A R

T in ci de n ce ra te

O p ti o n a l

C a lc u la ti n g

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

I n c id e n c e

R a te s

W o rk sh e e t

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

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

C o lu m n H

C o lu m n I

D A

R T in ci d en ce ra te

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

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

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

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

PN457984

MKARNS-REPAIR STOPLOG CENTER POST RECEIVERS

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

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

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

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

T h e a se p ar at e fo rm sh o w s th e w o rk -r el at ed in ju ry an d il ln es s to ta ls fo r th e ye ar in ea ch ca te g o ry

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

L og of W or k-

R el at ed

In ju ri es an d

Il ln es se s

L og

S u m m ar y

L og

S u m m ar y.

S u m m ar y

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

Y o u d o n

’t p o st t h e L o g

Y o u p o st o n ly th e

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

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

L o g

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

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

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

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

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

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

C h o o se O

O N

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

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

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

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

C h e c k t h e

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

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

Skin disorders

Respiratory conditions

Poisoning

Hearing loss

All other illnesses

Injury

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

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

P ar t 1

th ro ug h

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

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

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

Fo rm

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

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

, c al l y ou r l oc al O

A of fic e fo r h el p.

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

X Y Z

C om pa n y

A n yw he re M

F o rm ap p ro ve d O

M B n o

-0

D e a th

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

R e m a…

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.