Attachment_6_-_Monthly_Record_of_Exposure_Hours.pdf

Month Year

City

Describe The Case

(B1) (B2) (B3) (C) (D) (F)

(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)

0 0 0 0 0 0 0 0 0 0 0 0 Type of Contract (Choose One):

Construction Opn & Main. Civil Works Eng. Services Military Programs Dredging Other Rsch. & Dev.

Emerg. Opns.

Other

Date of injury or onset of illness

Classify the caseIdentify the person

State

Contract Number

USACE Command

On job transfer or restriction (days)

Away from work (days)

In ju ryOther record-able cases

Project Title

Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill (e.g. Second degree burns on right forearm from acetylene torch)

Check the "injury" column or choose one type of illness:

Contractor Name

Certification of Record Name of Person Submit. Record

Monthly Record of Work-Related Injuries/Illnesses & Exposure

In accordance with the provisions of EM 385-1-1, Section 01 Program Management, Paragraph 01.D Accident Reporting and Recording, sub-paragraphs 01.D.05, you (the Prime Contractor) shall provide a monthly record of all exposure and accident experience incidental to the work (this includes exposure and accident experience of the Prime Contractor and its sub-contractor(s). As a minimum , these records shall include exposure work hours and a record of occupational injuries and illnesses that include the data elements listed below. Definitional criteria for each data element is found in 29 CFR Part 1904. If the maintenance of OSHA 300 Logs are required by OSHA, most of this information can be obtained from those logs. If data on log provided below is revised after it is submitted to USACE, Contractor shall provide a revised report to the GDA. You must complete the USACE ENG Form 3394, Report of Accident Investigation Report for all recordable accidents. If you're not sure whether a case is recordable, call your local Safety and Occupational Health Office for help.

FUDS

(mo./day)

FUSRAP

IRP

Year to Date

Days away from work

Signature

USACE PRIME CONTRACTOR

Pr im e or

S ub

(P o r S

Company Name

(A)

Ag e

G en de r

(E) Where the event occurred (e.g. Loading dock north end)Date

Employee Began

Work on Job

Covered by

Contract

Job Title (e.g., Welder)

Sk in

D is or de r

R es pi ra to ry

C on di tio n

Po is on in g

H ea rin g

Lo ss

(M)

US Army Corps of Engineers

Job transfer or restriction

Enter the number of days the injured or ill worker was:

Remained at work

Using these categories, check ONLY the most serious result for each case:

Al l o th er

Ill ne ss es

Date

Exposure Hours Month

___ of ___Page

Death

USACE Office Overseeing Work

Ordinance/Expl. Cleanup Environmental Other

For Government Use Only TYPE OF WORK ACTIVITY (Choose One):

Environmental Remed.

Superfund

Record Of Injuries & Illnesses