Attachment_6_to_PWS.xls
XLS spreadsheet 47 KB Posted
- Attached to
- Secuirty Install services at three (3) U. S. Armed Forces Recruiting Offices in Mechanicsburg, PA
- Solicitation number
- W912DR-16-T-0072
About this file
This is Attachment 6 from the PWS
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Other files
| File | Type | Posted |
|---|---|---|
| A10_W912DR-16-T-0072.pdf | ||
| A10_W912DR-16-T-0072.pdf | ||
| Attachment_2_to_PWS.pdf | ||
| Attachment_1_to_PWS.pdf |
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Text version
Record Of Injuries & Illnesses
| USACE PRIME CONTRACTOR | |||||||||||||||||||||
| US Army Corps of Engineers | |||||||||||||||||||||
| Month | |||||||||||||||||||||
| Monthly Record of Work-Related Injuries/Illnesses & Exposure | Year | ||||||||||||||||||||
| USACE Command | |||||||||||||||||||||
| 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. | Contractor Name | ||||||||||||||||||||
| Contract Number | |||||||||||||||||||||
| Project Title | |||||||||||||||||||||
| City | State | ||||||||||||||||||||
| USACE Office Overseeing Work: | |||||||||||||||||||||
| Identify the person | Describe The Case | Classify the case | |||||||||||||||||||
| Using these categories, check ONLY the most serious result for each case: | Enter the number of days the injured or ill worker was: | Check the "injury" column or choose one type of illness: | |||||||||||||||||||
| (A) | (B1) | (B2) | (B3) | (C) | (D) | (E) | (F) | ||||||||||||||
| Company Name | Prime or Sub (P or S) | Age | Gender | Date Employee Began Work on Job Covered by Contract | Job Title (e.g., Welder) | Date of injury or onset of illness | Where the event occurred (e.g. Loading dock north end) | 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) | |||||||||||||
| (M) | |||||||||||||||||||||
| Death | Days away from work | Remained at work | On job transfer or restriction (days) | Away from work (days) | Injury | Skin Disorder | Respiratory Condition | Poisoning | Hearing Loss | All other Illnesses | |||||||||||
| (mo./day) | |||||||||||||||||||||
| Job transfer or restriction | Other record- able cases | ||||||||||||||||||||
| (G) | (H) | (I) | (J) | (K) | (L) | (1) | (2) | (3) | (4) | (5) | (6) | ||||||||||
| For Government Use Only | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||||
| TYPE OF WORK ACTIVITY (Choose One): | Type of Contract (Choose One): | ||||||||||||||||||||
| Construction | Environmental Remed. | Exposure Hours | Certification of Record | ||||||||||||||||||
| Opn & Main. | Superfund | Civil Works | Month | Name of Person Submit. Record | |||||||||||||||||
| Eng. Services | FUDS | Military Programs | Year to Date | ||||||||||||||||||
| Dredging | IRP | Other | Signature | ||||||||||||||||||
| Rsch. & Dev. | FUSRAP | Date | |||||||||||||||||||
| Emerg. Opns. | Ordinance/Expl. Cleanup | ||||||||||||||||||||
| Other | Environmental Other | Page | ___ of ___ |
&R&12Attachment 5
Sheet3
File details come from the government source that posted it. Updated .