PWS - FY25 B1 North Plains Appendix B.1 SSHO_Designation_Eng_Form_6282_2023Aug28.pdf

ENG FORM 6282, AUG 2023

U.S. Army Corps of Engineers (USACE)

SITE SAFETY & HEALTH OFFICER (SSHO) DESIGNATION LETTER

For use of this form, see EM 385-1-1; the proponent agency is CESO.

Purpose: This document designates personnel responsible for overseeing and ensuring the implementation of the prime contractor's Safety & Occupational Health (SOH) program. This designation letter will be signed by the company's official responsible for the SOH program (e.g., Corporate Safety Manager).

Submit the following documentation to the Government Designated Authority (GDA) as part of the Accident Prevention Plan: 1) This signed SSHO Designation Letter (Eng Form 6282); 2) An instructor-signed OSHA 30-hour card (or course completion certificate if within 90 days of completing the OSHA 30-hour training); and 3) proof of 24 hours of competency of SOH training within the last 3 years.

PART I: COMPLETED BY COMPANY'S SOH PROGRAM OFFICIAL

1. Project Name 2. Contract Number

3. Location

4. The designated SSHO on this form meets the minimum EM 385-1-1 training and experience requirements for the selected level below and is knowledgeable of the SOH requirements for this project and has the authority to stop work when required.

SSHO Level Experience Competency Training OSHA 30-Hour

Qualified or Competent Person

3 years of cumulative safety experience, within the last 10 years, managing or implementing a SOH program on projects similar in industry type, size, and complexity as the project described in the contract scope of work.

24 hours of documented formal classroom or online SOH-related training within the past five years and must maintain competency by taking 24 hours every three-year period for the duration of the contract.

Construction or General Industry

5 years of cumulative safety experience, within the last ten years, managing or implementing a SOH program on projects similar in industry type, size, and complexity as the project described in the contract scope of work.

24 hours of documented formal classroom or online SOH-related training within the past five years and must maintain competency by taking 24 hours every three-year period for the duration of the contract.

Construction or General Industry Level 1

Level 2

Level 3

5. Summary of required safety experience:

By my signature below, I certify that the information I provided on this form is true and correct to the best of my knowledge.

Company SOH Official Name Company SOH Official Title

Company SOH Official Signature Date

PART II: COMPLETED BY DESIGNATED SSHO

SSHO Name Date SSHO Signature

ENG FORM 6282, AUG 2023

U.S. Army Corps of Engineers (USACE)

SITE SAFETY & HEALTH OFFICER (SSHO) DESIGNATION LETTER

For use of this form, see EM 385-1-1; the proponent agency is CESO.

Purpose: This document designates personnel responsible for overseeing and ensuring the implementation of the prime contractor's Safety & Occupational Health (SOH) program. This designation letter will be signed by the company's official responsible for the SOH program (e.g., Corporate Safety Manager).

Submit the following documentation to the Government Designated Authority (GDA) as part of the Accident Prevention Plan: 1) This signed SSHO Designation Letter (Eng Form 6282); 2) An instructor-signed OSHA 30-hour card (or course completion certificate if within 90 days of completing the OSHA 30-hour training); and 3) proof of 24 hours of competency of SOH training within the last 3 years.

PART I: COMPLETED BY COMPANY'S SOH PROGRAM OFFICIAL

4. The designated SSHO on this form meets the minimum EM 385-1-1 training and experience requirements for the selected level below and is knowledgeable of the SOH requirements for this project and has the authority to stop work when required.

SSHO Level Experience Competency Training OSHA 30-Hour Qualified or Competent Person 3 years of cumulative safety experience, within the last 10 years, managing or implementing a SOH program on projects similar in industry type, size, and complexity as the project described in the contract scope of work.

24 hours of documented formal classroom or online SOH-related training within the past five years and must maintain competency by taking 24 hours every three-year period for the duration of the contract.

Construction or General Industry 5 years of cumulative safety experience, within the last ten years, managing or implementing a SOH program on projects similar in industry type, size, and complexity as the project described in the contract scope of work.

24 hours of documented formal classroom or online SOH-related training within the past five years and must maintain competency by taking 24 hours every three-year period for the duration of the contract.

Construction or General Industry By my signature below, I certify that the information I provided on this form is true and correct to the best of my knowledge.

PART II: COMPLETED BY DESIGNATED SSHO

1.0 darwin.chen@usace.army.mil 2023-05-05 Forms Design Team Darwin Chen 2023-08-30

SITE SAFETY & HEALTH OFFICER (SSHO) DESIGNATION LETTER

SITE SAFETY & HEALTH OFFICER (SSHO) DESIGNATION LETTER