W912P418B0022-0001.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print)

30-105-04EXCEPTION TO SF 30

APPROVED BY OIRM 11-84

STANDARD FORM 30 (Rev. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

This amendment provides attachments that w ere inadvertently omitted from the original solicitation and provides responses to questions received.

The response date and time is not extended.

1. CONTRACT ID CODE PAGE OF PAGES

1 2

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

16C. DATE SIGNED

BY

16B. UNITED STATES OF AMERICA15C. DATE SIGNED15B. CONTRACTOR/OFFEROR

(Signature of Contracting Officer)(Signature of person authorized to sign)

8. NAME AND ADDRESS OF CONTRACTOR (No., Street, County, State and Zip Code) X W912P418B0022

X 9B. DATED (SEE ITEM 11)

15-Aug-2018

10B. DATED (SEE ITEM 13)

9A. AMENDMENT OF SOLICITATION NO.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

X The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offer is extended, X is not extended.

Offer must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended by one of the following methods:

(a) By completing Items 8 and 15, and returning 1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE

RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN

REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE

CONTRACT ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(B).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

10A. MOD. OF CONTRACT/ORDER NO.

2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO.(If applicable)

6. ISSUED BY

3. EFFECTIVE DATE

13-Sep-2018

CODE

U.S. ARMY ENGINEER DISTRICT, BUFFALO

1776 NIAGARA STREET

BUFFALO NY 14207-3199

W912P4 7. ADMINISTERED BY (If other than item 6)

4. REQUISITION/PURCHASE REQ. NO.

CODE

See Item 6

FACILITY CODECODE

EMAIL:TEL:

W912P418B0022

SECTION SF 30 BLOCK 14 CONTINUATION PAGE

SUMMARY OF CHANGES

SECTION 00 10 00 - SOLICITATION

The following have been added by full text:

AMENDMENT 0001

Solicitation W912P418B0022 Amendment 0001

This Amendment 0001 addresses questions/comments that were received concerning the above

Solicitation.

Comment: Page 280 of the .pdf list 13 attachments that can be found in the “attachments” panel of the file. These attachments are not available.

Response: This amendment provides the attachments.

Comment/question: Sheet G-002, Note 2 indicates there is an attachment to the specifications further detailing the disposal site. I am unable to locate any additional information on the disposal site.

Response: Drawing RE-102 is provided in this Amendment.

Questions: Who is responsible for maintaining the disposal site? Who is responsible for E&S measures at the disposal site? In our previous work in Lake County, access to the disposal site was restricted during wet weather and by time of day which would greatly impact the cost of this project. Are these restrictions accounted for in the attachment indicated above?

Response: The disposal site is property of Lake County. Section 01 35 13 Paragraph 1.3.1 Lake

County Points of Contact is provided for further questions concerning this property. During the execution of the contract, a USACE Contracting Officer Representative (COR) point of contact will be available.

(End of Summary of Changes)

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ACTIVITY HAZARDS ANALYSIS

NWW Form 385-1 (Revised) April 2008

S e v e r i t y

Risk Assessment Code Matrix

Assess the impact of each hazard in terms of potential loss and cost, based on the probability and severity should an incident occur.

E = Extremely High Risk

H = High Risk

Probability

M = Moderate Risk

L = Low Risk

E

E

H

H

M

E

H

H

M

L

H

M

M

L

L

M

L

L

L

L

JOB STEPS

Break down the job into individual steps, e.g., mobilization, erect forms, erect scaffolding, install reinforcement bar, remove forms, demobilization.

HAZARDS

Identify the hazards, what are the man, machine, and environmental hazard factors of an operation. Note: include hazards that could potentially change the risk, such as weather, changing site conditions, abnormal operating procedures, etc. Do a change analysis when site conditions change.

ACTIONS TO ELIMINATE OR MINIMIZE HAZARDS

List the controls needed to eliminate or reduce the risks. Controls can be in the form of educational controls (training), physical controls (barriers, guards, signs, etc.), Administrative Controls, Personal Protective Equipment, or Engineering Controls. Risk avoidance is another alternative, are there ways to do the job differently so that risks aren't encountered.

RAC

EQUIPMENT

List equipment needed for the job.

TRAINING

List any specialized training or certifications needed for the job.

INSPECTION

List any inspection requirements, before, during, or after the job is completed.

8.0.1291.1.339988.308172

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Date AHA form was prepared or last revised.:

List project name:

For multiple job steps, use the highest obtained Risk Code. Note: the risk code is the residual risk after controls have been implemented. The following codes require the appropriate personnel approvals:

E = Division Commander (E = Extremely High Risk). Equates to loss of ability to accomplish mission if hazards occur during mission.

H = District Commander (H = High Risk). Results in significant degradation of mission capabilities if hazards occur during mission.

M = Program Manager, Project Manager, Project Engineer (M = Moderate). Minor injury, lost workday accident, compensable injury or illness, minor system damage, or minor property damage.

L = First Line Supervisor, Quality Assurance Representative (L = Low). Little or no impact on mission accomplishment.:

Continuously experiences or occurs very often. Likely to occur often in the life of an item with a probability of occurrence greater than 10-1 in that life.:

Occurs frequently. Several times in the life of an item with a probability of occurrence less than 10-1 but greater than 10-2 in that life.:

Occurs several times. Likely to occur some time in the life of an item with a probability of occurrence less than 10-2 but greater than 10-3 in that life.:

Unlikely but can reasonably be expected to occur. Unlikely but possible to occur in the life of an item with a probability of occurrence less than 10-3 but greater than 10-6 in that life.:

Unlikely to occur but possible. So unlikely, it can be assumed occurrence may not be experienced with a probability of occurrence less than 10-6 in that life.:

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Could result in injury or occupational illness resulting in one or more lost work days, loss exceeding $10K but less than $200K, or mitigable (minor) environmental damage without violation of law or regulation where restoration activities can be accomplished for the environment. Lost day due to injury or illness not exceeding 3 months (accident risk).:

Could result in injury or illness not resulting in a lost work day, loss exceeding $2K but less than $10K, or minimal environmental damage not violating law or regulation. A first aid or minor medical treatment (accident risk). Slight equipment or system damage but fully functional and serviceable. Little or no property or environmental damage.:

Describe specific activity in which this AHA form is being prepared for, i.e., Unit 2 Annual Maintenance.:

Give location, i.e., McNary Dam Fish Facility.:

Who prepared this analysis?:

JobSteps:

Hazards:

Actions:

Select risk assessment code from drop down list based on matrix above:

Equipment:

Training:

Inspections:

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APP Checklist

CONTRACTOR ACCIDENT PREVENTION PLAN (APP) CHECKLIST

(EM 385-1-1, Appendix - A, dated 30 Nov 2014)

Minimum Basic Outline for APP The APP is the Contractor Safety and Health Program Document. The following Site Specific Areas will be addressed:

NOTE: 1. Contractor will complete Checklist and Submit with their APP.

NOTE: 2. Contractor APP WILL be submitted in format below.

NOTE: 3. Safety Office will review Contractor APP and return to PM /COR.

NOTE: 4. Contractor APP's ARE NOT APPROVED by the USACE, only found as Acceptable or Non-Acceptable.

Safety Office Review Status: ACCEPTED BY/DATE: NOT ACCEPTED BY/DATE:

Contractor Name: _______________________________________________________

Contract No: _________________________________

Project Title & Location: Included? Location

Page(s) Yes No N/A

ALL CHECKLIST ITEMS WILL BE COMPLETED!

1. SIGNATURE SHEET. Title, signature, and phone number of the following:

a. Plan Preparer (qualified person, Competent Person such as corporate safety staff person, QC).

b. Plan Approval by company/corporate officers authorized to obligate the company (e.g. owner company president, regional vice president etc.)

c. Plan Concurrence (e.g. Chief of Operations, Corporate Chief of Safety, Corporate Industrial Hygienist, project manager or superintendent, project safety professional, project QC). Provide concurrence of other applicable corporate and project personnel (Contractor).

2. BACKGROUND INFORMATION. List the following:

a. Contractor;

b. Contract number;

c. Project name;

d. Brief project description, description of work to be performed, and location (map);

equipment to be used; anticipated high risk activities

e. Major phases of work anticipated and activities that will require an AHA

3. STATEMENT OF SAFETY AND HEALTH POLICY. Provide a copy of your current corporate/company Safety & Health Policy Statement, detailing commitment to providing a safe and healthful workplace for all employees. The Contractor’s written safety program goals, objectives, and accident experience goals for this contract should be provided.

4. RESPONSIBILITIES AND LINES OF AUTHORITIES. Provide the following:

a. A statement of the employer’s ultimate responsibility for the implementation of his SOH program for his own employees, all sub-contractors and all others on the worksite.

b. Identification and accountability of personnel responsible for safety at both corporate and project level. Contracts specifically requiring safety or industrial hygiene personnel shall include a copy of their resumes. Per EM 385-1-1 01.A.17, the SSHO is required to have as a minimum the OSHA 30-hour Construction Safety course and construction industry safety experience; and must be on-site at all times when work is being performed.

c. The names of Competent and/or Qualified Person(s) and proof of competency/qualification to meet specific OSHA Competent/Qualified Person(s) requirements must be attached. The District SOHO will review the qualifications for acceptance;

d. Requirements and details of the employers Risk Management Process (i.e.AHAs)

e. Requirements for activity specific AHAs to be submitted and accepted at preparatory meetings, prior to work being performed;

f. Requirements that no work by the Contractor shall be performed unless a designated CP/SSHO is present at the job site;

g. Policies and procedures regarding noncompliance with safety requirements (to include disciplinary actions for violation of safety requirements) should be identified;

h. Lines of authority;

i. Provide written company procedures for holding managers and supervisors accountable for safety.

5. SUBCONTRACTORS AND SUPPLIERS. If applicable, provide procedures for coordinating SOH activities with other employers on the job site:

a. Identification of subcontractors and suppliers (if known);

b. Safety responsibilities of subcontractors and suppliers.

6. TRAINING.

a. Requirements for new hire SOH orientation training at the time of initial hire of each new employee.

b. Requirements for mandatory training and certifications that are applicable to this project (e.g., explosive actuated tools, confined space entry, crane operator, diver, vehicle operator, HAZWOPER training and certification, PPE) and any requirements for periodic retraining/recertification.

c. Procedures for periodic safety and health training for supervisors and employees.

d. Requirements for emergency response training.

7. SAFETY AND HEALTH INSPECTIONS.

a. Specific assignment of responsibilities for a minimum daily job site safety and health inspection during periods of work activity: Who will conduct (e.g., SSHO, PM, safety professional, QC, supervisors, employees – depends on level of technical proficiency needed to perform said inspections), proof of inspector’s training/qualifications, when inspections will be conducted, procedures for documentation, deficiency tracking system, and follow-up procedures;

b. Any external inspections/certifications that may be required (e.g., USCG).

8. MISHAP REPORTING AND INVESTIGATION. The Contractor shall identify person(s) responsible to provide the following:

a. Exposure data (man-hours worked);

b. Accident investigations, reports, and logs: Report all accidents/incidents as soon as possible but not more than 4 hours afterwards to the Contracting Officer/Representative (KO/COR). The contractor shall thoroughly investigate the incident/accident per Section 01.D and, if applicable, submit the findings of the investigation along with appropriate corrective actions to the KO/COR in the prescribed format as soon as possible. Implement corrective actions as soon as reasonably possible and provide notice to the KO/COR when corrective actions are completed;

c. The following require immediate accident notification:

(1) A fatal injury;

(2) A permanent total disability;

(3) A permanent partial disability;

(4) The hospitalization of three or more people resulting from a single occurrence;

(5) Property damage of $200,000 or more.

9. PLANS (PROGRAMS, PROCEDURES) REQUIRED BY THE SAFETY MANUAL. Based on a risk assessment of contracted activities and on mandatory OSHA compliance programs, the Contractor shall address all applicable occupational risks and compliance plans.

Using the EM 385-1-1 as a guide, plans may include but not be limited to:

a. Fatigue Management Plan (01.A.20);

b. Emergency Plans (01.E);

c. Site Sanitation/ Housekeeping Plan (Section 02.B);

d. Medical Support Agreement (03.A.01; 03.A.03);

e. Blood Borne Pathogen Program (03.A.05);

f. Exposure Control Plan (03.A.05);

g. Automatic External Defibrillator (AED) Program (03.B.04);

h. Site Layout Plan (04.A);

i. Access / Haul Road Plan (04.B);

j. Hearing Conservation Program (05.C);

k. Respiratory Protection Plan (05.G);

l. Health Hazard Control Program (06.A);

m. Hazard Communication Program (06.B.01);

n. Process Safety Management Plan (06.B.04);

o. Lead Compliance Plan (06.C.02 & specifications);

p. Asbestos Abatement Plan (06.C.03 & specifications);

q. Radiation Safety Program (06.F);

r. Abrasive Blasting Procedures (06.I.01);

s. Heat Stress Monitoring Plan (HSMP) (06.J.02);

t. Cold Stress Monitoring Plan (CSMP) (06.J.04);

u. Indoor Air Quality Management Plan (06.L);

v. Mold Remediation Plan (06.L.04);

w. Chromium (VI) Exposure Evaluation (06.M);

x. Crystalline Silica Evaluation (06.N.02) ;

y. Lighting Plan for Night Operations (07.A.06);

z. Traffic Control Plan (08.C.05);

aa. Fire Prevention Plan (09.A.01);

bb. Wild Land Fire Management Plan (09.L);

cc. Arc Flash Hazard Analysis (11.B);

dd. Assured Equipment Grounding Control Program (AEGCP) (11.D.05, Appendix E);

ee. Hazardous Energy Control Program & Procedures (12.A.01);

ff. Standard Pre-Lift Plan – Load Handling Equipment (16.A.03);

gg. Critical Lift Plan – Load Handling Equipment (16.H);

hh. Naval Architecture Analysis – Load Handling Equipment (Floating) (16.L);

ii. Floating Plant Inspection and Certification (19.A.01);

jj. Severe Weather Plan for Marine Activities (19.A.03);

kk. Emergency Plan for Marine Activities (19.A.04);

ll. Man Overboard/Abandon Ship Procedures (19.A.04);

mm. Float Plan for Launches, Motorboats, and Skiffs (19.F.04);

nn. Fall Protection & Prevention Plan (21.D);

oo. Demolition/Renovation Plan (to include engineering survey) (23.A);

pp. Rope Access Work Plan (24.H2);

qq. Excavation / Trenching Plan (25.A.01);

rr. Fire Prevention and Protection Plan for Underground Construction (26.D.01);

ss. Compressed Air Work Plan for Underground Construction (26.D.01);

tt. Erection and Removal Plan for Formwork and Shoring (27.C);

uu. Precast Concrete Plan (27.D.01);

vv. Lift Slab Plans (27.E);

ww. Masonry Bracing Plan (27.F.01);

xx. Steel Erection Plan (28.B);

yy. Explosives Safety Site Plan (ESSP) (29.A);

zz. Blasting Safety Plan (29.A; 26.J);

aaa. Dive Operations Plan (30.A.14 & 30.A.16);

bbb. Safe Practices Manual for Diving Activities (30.A.15);

ccc. Emergency Management Plan for Diving (30.A.18);

ddd. Tree Felling and Maintenance Program (31.A.01);

eee. Aircraft/Airfield Construction Safety & Phasing Plan (CSPP) (32.A.02);

fff. Aircraft/Airfield Safety Plan Compliance Document (SPCD) (32.A.02);

ggg. Site Safety and Health Plan for HTRW (33.B);

hhh. Confined Space Entry Procedures (34.A.05);

iii. Confined Space Program (34.A.06);

10. RISK MANAGEMENT PROCESSES. Detailed project-specific hazards and controls shall be provided by an Activity Hazard Analysis (01.A.14, 01.A.15) for each major phase/activity of work.

CONTRACTOR QUALITY CONTROL PLAN TEMPLATE

ITEMS IN RED TEXT MUST BE COMPLETED BY THE

CONTRACTOR

INDICATE “N/A” IF NOT APPLICABLE

CONTRACTOR QUALITY CONTROL PLAN

Name of Contract Contract No. W912P4-##-#-####

Name of Contractor

A. Quality Control Organization

Name, President Name, Vice President Name, Quality Control System Manager Name, Alternate Quality Control System Manager Name, Site Superintendent Name, Responsible for preparation and certifying pay estimates Name, Responsible for executing contract modification Name, Responsible for certifying contract submittals

A chart showing lines of authority is attached to this CQC Plan.

B. Resumes of the following individuals are attached to this CQC Plan:

1. CQC System Manager

2. Alternate CQC System Manager

3. Individual(s) responsible for certifying payment requests.

4. Individual(s) responsible for executing contract modifications.

5. Individual(s) responsible for certifying contract submittals.

6. Others

C. [Applicable if the contract amount exceeds $1 million] The CQC System Manager and Alternate CQC System Manager have completed the course entitled "Construction Quality Management For Contractors". Copies of their course certificates are attached to this CQC Plan.

D. A copy of the letter to the CQC System Manager and Alternate CQC System Manager, signed by an authorized official of the firm, which describes the responsibilities and delegates sufficient authorities to adequately perform the functions of the CQC System Manager, including authority to stop work which is not in compliance with the contract is attached to this CQC Plan.

E. Copies of the CQC System Manager letters of direction to all other various quality control representatives outlining duties, authorities, and responsibilities are attached to this CQC Plan.

F. The following subcontractors will be utilized on this project:

Name of subcontractor Work to be completed by this subcontractor

G. The CQC staff will implement the three phase control system for all aspects of the work specified. The three phase control system is described in detail in specification section 01 45 01.

Additionally, the following procedures will be used to monitor dredging quantities and locations to ensure that limits and quantities specified by the Contracting Officer are attained:

[Insert description of intended quantity and location monitoring procedures.]

H. The Major Definable Features of work for this project are identified in a table attachment to this CQC Plan.

I. For payment purposes, the Bid Items have been broken down into a Schedule of Values. The proposed Schedule of Values is identified in a table attachment to this CQC Plan.

J. Preparatory and Initial Phase inspections will be tracked utilizing the table attached to this CQC Plan.

K. Deficiencies will be tracked from identification through acceptable corrective action utilizing the table attached to this CQC Plan.

L. Submittals will be tracked utilizing the Submittal Register attached to this CQC Plan.

M. The CQC Report attached to this CQC Plan will be utilized. CQC Reports will be prepared daily and submitted to the Government Representative. Other reports to be attached to the daily CQC report are:

Preparatory Phase Inspection Checklist Initial Phase Inspection Checklist Others as appropriate

N. Plan of Operations - The following Plan of Operations will be used for all construction operations:

[Insert description of intended Plan of Operations to be implemented, including, but not limited to, equipment to be used, specific stations where work is to be perfomed, sequence of operations, etc.]

O. List any other contract specific items

_______________/Signature/___________________ Name Title

Attachments:

Chart showing lines of authority Resumes CQC course certificates [If contract amount exceed $1 million] Letter to the CQC System Manager and Alternate CQC System Manager CQC System Manager letters of direction Table: Major Definable Features of Work Table: Schedule of Values Table: Tracking - Preparatory and Initial Phase Inspections Table: Deficiency Tracking Submittal Register CQC Report Other QC reports

[INSERT CHART SHOWING LINES OF AUTHORITY]

[INSERT RESUMES]

[INSERT CQC COURSE CERTIFICATES IF CONTRACT AMOUNT EXCEEDS $1

MILLION]

[INSERT LETTER TO THE CQC SYSTEM MANAGER AND ALTERNATE CQC SYSTEM

MANAGER]

[INSERT CQC SYSTEM MANAGER LETTERS OF DIRECTION]

Major Definable Features of Work

ID No. Major Definable Feature of Work [Complete Table]

Schedule of Values

Bid Item No.

Activity

Description Feature ID

Amount

The total amount of all activities under a Bid Item must equal the amount of the Bid Item.

Feature ID No. relates the Major Identifiable Feature of Work.

When the contract requires As-Built Record Drawings, include an activity and dollar amount.

Tracking - Preparatory and Initial Phase Inspections

Major Feature of Work Preparatory Scheduled

Conducted

Initial Scheduled Initial Conducted

Deficiency Tracking

Item No. Description Date Noted

Date Scheduled for Correction

Corrected

[INSERT COMPLETED SUBMITTAL REGISTER]

[INSERT CQC REPORT FORMS TO BE USED]

[INSERT OTHER QC REPORT FORMS AS APPLICABLE]

CONTRACTOR QUALITY CONTROL PLAN CHECKLIST

Contract No.

CHECK LIST ITEM Found on Yes No N/A Page(s)

1. A description of the quality control organization, including a chart showing lines of authority.

2. Acknowledgment that the CQC staff must implement the three phase control system for all aspects of the work specified

3. The name , qualifications (in resume format), duties, responsibilites, and authorities of each person assigned a CQC function

a. CQC System Manager

b. Alternate CQC System Manager

c. Individual(s) responsible for certifying that all submittals are in compliance with the contract requirements

d. Individual(s) responsible for executing contract payments

e. Individual(s) responsible for certifying payment requests

f. Others

4. Documentation that the CQC System Manager and Alternate CQC Manager have completed the course entitled "Construction Quality Management for Contractors".

5. A copy of the letter to the CQC System Manager signed by an authorized official of the firm which describes the responsibilites and delegates sufficient authorities to adequately perform the functions of the CQC System Manager, including authority to stop work which is not in compliance with the contract.

6. The CQC System Manager must issue letters of direction to all other various quality control representatives outlining duties, authorities, and responsibilities. Copies of these letters must be furnished to the Government.

7. Procedures for scheduling, reviewing, certifying, and managing submittals, including those of subcontractors, offsite fabricators, suppliers, and purchasing agents.

8. Control, verification, and acceptance testing procedures for each test to include the test name, specification paragraph requiring test, feature of work to be tested, test frequency, and person responsible for each test.

9. Name and address of proposed laboratory facilities to be utilized.

10. Procedures for tracking preparatory, initial, and follow‐up control phases and control, verification, and acceptance test including documentation.

11. Procedures for tracking construction deficiencies from identification through acceptable corrective action. These procedures must establish verification that identified deficiencies have been corrected.

12. Reporting procedures, including proposed reporting formats.

At minimum, the QC Report presented in the contract must be utilized.

13. Reporting subcontractors and the associated activity of work which the subcontractor will perform.

14. A list of definable features of work.

15. Contract specific items

Included ?

Contractor QC Plan Checklist (Dec2011).xlsx

CONTRACTOR QUALITY CONTROL REPORT

Contract Number

Name of Project

Prime Contractor

Report Number

Todays’ Weather

General Description

Temperature Range

Precipitation

Were there any delays in the work progress today? __________Yes __________No If “Yes”, explain‐

Describe any verbal instructions given by Government personnel (include name of person giving instructions)

Has anything developed which might lead to a change order or claim? _________Yes _________No If “Yes”, explain‐

Contractor / Subcontractors on Site

Name of Contractor Hours on Site

Area of Responsibility

Contractor Quality Control report (Dec2011).docx

Prime Contractor/subcontractor Workforce

Employer Trade No. Hours

Major Items of Equipment

Type/Capacity Contractor No. Oper.

Hours

Standby

Repair

Work performed this date (enter all activities started but not previously reported as completed)

Actual No. Actual Start

Actual Finish

Description of work performed this date and major deliveries today. Identify contractor performing the work

Off‐site Surveillance Activities, including actions taken:

Definable Features of Work – History:

Definable Features of work (list All) ‐‐‐‐‐‐‐‐‐‐‐‐Attach checklist for each Preparatory or Initial Phase Inspection held this date

Inspection

Initial Inspection

Unit Price Work Completed This Date:

CLIN Description Unit Contract Quality

Quantity Completed This Date

Total This

Deficiencies Noted or Corrected This Date:

Act. No. Description of Deficiency Noted Corrected

CQC Testing:

Act. No. Description – Include reference to contract specification Test Results Pass/Fail

The following Equipment Safety Checklists are attached to this report:

Were there any Lost Time Accidents this date? __________Yes __________No

If “Yes”, attach accident report

Safety Inspections: Identify results of all safety inspections and meetings this date. State what was checked and instructions given and corrective actions taken.

User Schooling Conducted:

Act. No. Description of Schooling and Names of Participants

Materials Received (note quantity of materials received, inspection results, and storage provided):

Other General Comments:

The following items are attached to this CQC Report:

CONTRACTOR CERTIFICATION

On behalf of the contractor, I certify that this report is complete and correct and all equipment and material used and work performed during this reporting period are in compliance with the contract plans and specifications, to the best of my knowledge, except as noted above.

Contract Quality Control Manager_______________________________________________________

Signature___________________________________________________________________________

Date_______________________________________________________________________________

a. ACTIVITY AT TIME OF ACCIDENT

a. SEVERITY OF ILLNESS/INJURY

b. TYPE OF CONSTRUCTION EQUIPMENT

g. HAZARDOUS/TOXIC WASTE

ACTIVITY

b. TIME OF ACCIDENT (Military Time)

GOVERNMENT

ENG FORM 3394, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 1 of 13 Pages

REPORT NO.

1. ACCIDENT CLASSIFICATION

UNITED STATES ARMY CORPS OF ENGINEERS

ACCIDENT INVESTIGATION REPORT

For use of this form, see Help Menu and USACE Supplement to AR 385-40 The proponent agency is CESO

CIVILIAN

REQUIREMENT

CONTROL SYMBOL:

CEEC-S-8 (R2)

(For safety staff only)

EROC CODE

PERSONNEL CLASSIFICATION INJURY/ILLNESS/FATAL PROPERTY DAMAGE MOTOR VEHICLE INVOLVED DIVING

MILITARY

CONTRACTOR

PUBLIC FATAL OTHER

FIRE INVOLVED OTHER

OTHERFIRE INVOLVED

2. PERSONAL DATA

a. NAME (Last, First MI.) b. AGE c. SEX

MALE FEMALE

d. SOCIAL SECURITY NUMBER e. GRADE

f. JOB SERIES/TITLE g. DUTY STATUS AT TIME OF ACCIDENT

ON DUTY TDY

OFF DUTY

h. EMPLOYMENT STATUS AT TIME OF ACCIDENT

ARMY ACTIVE

PERMANENT

TEMPORARY

OTHER (Specify)

ARMY RESERVE

FOREIGN NATIONAL

STUDENT

VOLUNTEER

SEASONAL

3. GENERAL INFORMATION

a. DATE OF ACCIDENT

(YYYYMMDD)

hrs.

c. EXACT LOCATION OF ACCIDENT

e. CONTRACT NUMBER

CIVIL WORKS MILITARY

f. TYPE OF CONTRACT

CONSTRUCTION

A/E

SERVICE

DREDGE

DERP

OTHER (Specify)IRP

SUPERFUND

d. CONTRACTOR'S NAME

(1) PRIME

(2) SUBCONTRACTOR

4. CONSTRUCTION ACTIVITIES ONLY (Fill in line and corresponding code number in box from list - see help menu)

b. ESTIMATED

DAYS LOST

a. CONSTRUCTION ACTIVITY (CODE)

(CODE)

5. INJURY/ILLNESS INFORMATION (Include name on line and corresponding code number in box for items e, f & g - see help menu)

c. ESTIMATED DAYS

HOSPITALIZED

d. ESTIMATED DAYS

RESTRICTED DUTY

e. BODY PART AFFECTED

PRIMARY

SECONDARY

f. NATURE OF ILLNESS / INJURY (CODE)

g. TYPE AND SOURCE OF INJURY/ILLNESS

TYPE

SOURCE

6. PUBLIC FATALITY (Fill in line and correspondence code number in box - see help menu)

(CODE) b. PERSONAL FLOTATION DEVICE USED?

YES NO N/A

a. ACTIVITY AT TIME OF ACCIDENTa. ACTIVITY AT TIME OF ACCIDENT

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 2 of 13

7. MOTOR VEHICLE ACCIDENT

a. TYPE OF VEHICLE b. TYPE OF COLLISION c. SEAT BELTS USED NOT USED NOT APPLICABLE

(1) FRONT SEAT

(2) REAR SEAT

SIDE SWIPE

BROADSIDE

HEAD ON

ROLL OVER

REAR END

BACKING

PICKUP/VAN

TRUCK

AUTOMOBILE

8. PROPERTY MATERIAL INVOLVED

a. NAME OF ITEM b. OWNERSHIP c. AMOUNT OF DAMAGE

(1)

(2)

(3)

9. VESSEL/FLOATING PLANT ACCIDENT (Fill in line and correspondence code number in box from list - see help menu)

10. ACCIDENT DESCRIPTION (Use additional paper, if necessary, see attached page 4.)

11. CAUSAL FACTOR(s) (Read instructions before completing)

a. (Explain YES answers in item 13)

YES NO

DESIGN: Was design of facility, workplace or equipment a factor?

INSPECTION/MAINTENANCE: Were inspection & maintenance 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?

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?

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?

b. WAS A WRITTEN JOB/ACTIVITY HAZARD ANALYSIS COMPLETED FOR TASK BEING PERFORMED AT TIME OF ACCIDENT? (If yes, attach a copy.)

12. TRAINING

a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK?

YES NO

b. TYPE OF TRAINING

CLASSROOM ON JOB

c. DATE OF MOST RECENT FORMAL

TRAINING (YYYYMMDD)

13. 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)

a. DIRECT CAUSE(s) (Attach additional sheets as needed, See page 4)

b. INDIRECT CAUSE(s) (Attach additional sheets as needed, See page 5)

CONCUR

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 3 of 13 Pages

14. ACTION(s) TAKEN, ANTICIPATED OR RECOMMENDED TO ELIMINATE CAUSE(s)

DESCRIBE FULLY (Attach additional sheets as necessary, See page 5)

15. DATES FOR ACTIONS IDENTIFIED IN BLOCK 14.

a. BEGINNING (YYYYMMDD) b. ANTICIPATED COMPLETION (YYYYMMDD)

16. MANAGEMENT REVIEW (1st)

c. DATE SIGNED

e. CORPS SIGNATURE, SUPERVISOR COMPLETING REPORT

e. CONTRACTOR SIGNATURE, SUPERVISOR COMPLETING REPORTc. DATE SIGNED

d. TITLE OF SUPERVISOR COMPLETING REPORT

d. TITLE OF SUPERVISOR COMPLETING REPORT

f. ORGANIZATION IDENTIFIER (Division, Branch, Section, etc.,) g. OFFICE SYMBOL

a. b. c. COMMENTSNONCONCUR

TITLEDATE (YYYYMMDD) SIGNATURE

17. MANAGEMENT REVIEW (2nd - Chief Operations, Construction, Engineering, etc.,)

a. b. c. COMMENTSNONCONCUR

18. SAFETY AND OCCUPATIONAL HEALTH OFFICE REVIEW

a. b. c. ADDITIONAL ACTIONS/COMMENTSNONCONCUR

19. COMMAND APPROVAL

COMMENTS

DATE (YYYYMMDD) COMMANDER SIGNATURE

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 4 of 13 Pages

10. ACCIDENT DESCRIPTION (Continuation)

13a. DIRECT CAUSE(s) (Continuation)

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 5 of 13 Pages

13b. INDIRECT CAUSE(s) (Continuation)

14. ACTION(s) TAKEN, ANTICIPATED, OR RECOMMENDED TO ELIMINATE CAUSE(s) (Continuation)

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 6 of 13 Pages

GENERAL. Complete a separate report for each person who was injured, caused, or contributed to the accident (excluding uninjured personnel and witnesses).

Use of this form for reporting USACE employee first-aid type injuries not submitted to the Office of Workers' Compensation Programs (OWCP) shall be at the discretion of the FOA commander. Please type or print legibly. Appropriate items shall be marked with an "X" in box(es). If additional space is needed, provide the information on a separate sheet and attach to the completed form. Ensure that these instructions are forwarded with the completed report to the designated management reviewers indicated in sections 16 and 17.

INSTRUCTIONS FOR SECTION 1 - ACCIDENT CLASSIFICATION

(Mark All Boxes That Are Applicable)

a. GOVERNMENT. Mark "CIVILIAN" box if accident involved government civilian employee; mark "MILITARY" box if accident involved U.S. military personnel.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in any government civilian employee injury, illness, or fatality that requires the submission of OWCP Forms CA-1 (injury), CA-2 (illness) or CA-6 (fatality) to OWCP; mark if accident resulted in military personnel lost-time or fatal injury or illness.

(2) PROPERTY DAMAGE - Mark the appropriate box if accident resulted in any damage of $1000 or more to government property (including motor vehicles).

(3) VEHICLE INVOLVED - Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are marked.

(4) DIVING ACTIVITY - Mark if the accident involved an in-house USACE diving activity.

b. CONTRACTOR.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in any contractor lost-time injury/illness or fatality.

(2) PROPERTY DAMAGE - Mark the appropriate box if accident resulted in any damage of $1000 or more to contractor property (including motor vehicles).

(3) VEHICLE INVOLVED - Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are marked.

(4) DIVING ACTIVITY - Mark if the accident involved a USACE Contractor diving activity.

c. PUBLIC.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in public fatality or permanent total disability. (The "OTHER" box will be marked when requested by the FOA to report an unusual non-fatal public accident that could result in claims against the government or as otherwise directed by the FOA Commander).

(2) VOID SPACE - Make no entry.

(3) VEHICLE INVOLVED - Mark if accident resulted in a fatality to a member of the public and involved a motor vehicle, regardless of whether "INJURY/lLLNESS/ FATALlTY" is marked.

(4) VOID SPACE - Make no entry.

INSTRUCTIONS FOR SECTION 2 - PERSONAL DATA

a. NAME - (MANDATORY FOR GOVERNMENT ACCIDENTS. OPTIONAL AT THE DISCRETION OF THE FOA COMMANDER FOR CONTRACTOR AND PUBLIC ACCIDENTS). Enter last name, first name, middle initial of person involved.

b. AGE - Enter age.

c. SEX - Mark appropriate box.

d. SOCIAL SECURITY NUMBER - (FOR GOVERNMENT PERSONNEL ONLY) Enter the social security number (or other personal identification number if no social security number issued).

e. GRADE - (FOR GOVERNMENT PERSONNEL ONLY) Enter pay grade. Example: 0-6; E-7; WG-8; WS-12; GS-11; etc.

f. JOB SERIES/TlTLE - For government civilian employees enter the pay plan, full series number, and job title, e.g., GS-O810/Civil Engineer. For military personnel enter the primary military occupational specialty (PMOS), e.g., 15A30 or 11G50. For contractor employees enter the job title assigned to the injured person, e.g., carpenter, laborer, surveyor, etc.

g. DUTY STATUS - Mark the appropriate box.

(1) ON DUTY - Person was at duty station during duty hours or person was away from duty station during duty hours but on official business at time of the accident.

(2) TDY - Person was on official business, away from the duty station and with travel orders at time of accident. Line-of-duty investigation required.

(3) OFF DUTY - Person was not on official business at time of accident.

h. EMPLOYMENT STATUS - (FOR GOVERNMENT PERSONNEL ONLY) Mark the most appropriate box. If "OTHER" is marked, specify the employment status of the person.

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 7 of 13 Pages

INSTRUCTION FOR SECTION 3 - GENERAL INFORMATION

a. DATE OF ACCIDENT - Enter the month, day, and year of accident.

b. TIME OF ACCIDENT - Enter the local time of accident in military time. Example: 1430 hrs (not 2:30 p.m.).

c. EXACT LOCATION OF ACCIDENT - Enter facts needed to locate the accident scene, (installation/project name, building number, street, direction and distance from closest landmark, etc.).

d. CONTRACTOR NAME

(1) PRIME - Enter the exact name (title of firm) of the prime contractor.

(2) SUBCONTRACTOR - Enter the name of any subcontractor involved in the accident.

e. CONTRACT NUMBER - Mark the appropriate box to identify if contract is civil works, military, or other: if "OTHER" is marked, specify contract appropriation on line provided. Enter complete contract number of prime contract, e.g., DACW 09-85-C-0100.

f. TYPE OF CONTRACT - Mark appropriate box. A/E means architect/engineer. If "OTHER" is marked, specify type of contract on line provided.

g. HAZARDOUS/TOXIC WASTE ACTIVITY (HTW) - Mark the box to identify the HTW activity being performed at the time of the accident. For Superfund, DERP, and Installation Restoration Program (IRP) HTW activities include accidents that occurred during inventory, predesign, design, and construction. For the purpose of accident reporting, DERP Formerly Used DoD Site (FUDS) activities and IRP activities will be treated separately. For Civil Works O&M HTW activities mark the "OTHER" box.

INSTRUCTIONS FOR SECTION 4 - CONSTRUCTION ACTIVITIES

a. CONSTRUCTION ACTIVITY - Select the most appropriate construction activity being performed at time of accident from the list below. Enter the activity name and place the corresponding code number identified in the box.

CONSTRUCTION ACTIVITY LIST

1. MOBILIZATION

2. SITE PREPARATION

3. EXCAVATION/TRENCHING

4. GRADING (EARTHWORK)

5. PIPING/UTILITIES

6. FOUNDATION

7. FORMING

8. CONCRETE PLACEMENT

9. STEEL ERECTION

10. ROOFING

11. FRAMING

12. MASONRY

13. CARPENTRY

14. ELECTRICAL

15. SCAFFOLDING/ACCESS

16. MECHANICAL

17. PAINTING

18. EOUIPMENT/MAINTENANCE

19. TUNNELING

20. WAREHOUSING/STORAGE

21. PAVING

22. FENCING

23. SIGNING

24. LANDSCAPING/IRRIGATION

25. INSULATION

26. DEMOLITION

b. TYPE OF CONSTRUCTION EQUIPMENT - Select the equipment involved in the accident from the list below. Enter the name and place the corresponding code number identified in the box. If equipment is not included below, use code 24, "OTHER", and write in specific type of equipment.

CONSTRUCTION EQUIPMENT

1. GRADER

2. DRAGLINE

3. CRANE (ON VESSEL/BARGE)

4. CRANE (TRACKED)

5. CRANE (RUBBER TIRE)

6. CRANE (VEHICLE MOUNTED)

7. CRANE (TOWER)

8. SHOVEL

9. SCRAPER

10. PUMP TRUCK (CONCRETE)

11. TRUCK (CONCRETE/TRANSIT MIXER)

12. DUMP TRUCK (HIGHWAY)

13. DUMP TRUCK (OFF HIGHWAY)

14. TRUCK (OTHER)

15. FORKLIFT

16. BACKHOE

17. FRONT-END LOADER

18. PILE DRIVER

19. TRACTOR (UTILITY)

20. MANLIFT

21. DOZER

22. DRILL RIG

23. COMPACTOR/VIBRATORY ROLLER

24. OTHER

INSTRUCTIONS FOR SECTION 5 - INJURY/ILLNESS INFORMATION

a. SEVERITY OF INJURY/ILLNESS - Reference paragraph 2-10 of USACE Supplement 1 to AR 385-40 and enter code and description from list below.

NOI NO INJURY

FAT FATALITY

PTL PERMANENT TOTAL DISABILITY

PPR PERMANENT PARTIAL DISABILITY

LWD LOST WORKDAY CASE INVOLVING DAYS AWAY FROM WORK

NLW RECORDABLE CASE WITHOUT LOST WORKDAYS

RFA RECORDABLE FIRST AID CASE

NRI NON-RECORDABLE INJURY

b. ESTIMATED DAYS LOST - Enter the estimated number of workdays the person will lose from work.

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 8 of 13 Pages

c. ESTIMATED DAYS HOSPITALIZED - Enter the estimated number of workdays the person will be hospitalized.

d. ESTIMATED DAYS RESTRICTED DUTY - Enter the estimated number of workdays the person, as a result of the accident, will not be able to perform all of their regular duties.

e. BODY PART AFFECTED - Select the most appropriate primary and when applicable, secondary body part affected from the list below. Enter body part name on line and place the corresponding code letters identifying that body part in the box.

GENERAL BODY AREA CODE BODY PART NAME

ARM/WRIST AB ARM AND WRIST

AS ARM OR WRIST

TRUNK, EXTERNAL B1 SINGLE BREAST

MUSCULATURE B2 BOTH BREASTS

B3 SINGLE TESTICLE

B4 BOTH TESTICLES

BA ABDOMEN

BC CHEST

BL LOWER BACK

BP PENIS

BS SIDE

BU UPPER BACK

BW WAIST

BZ TRUNK OTHER

HEAD, INTERNAL C1 SINGLE EAR INTERNAL

C2 BOTH EARS INTERNAL

C3 SINGLE EYE INTERNAL

C4 BOTH EYES INTERNAL

CB BRAIN

CC CRANIAL BONES

CD TEETH

CJ JAW

CL THROAT, LARYNX

CM MOUTH

CN NOSE

CR THROAT, OTHER

CT TONGUE

CZ HEAD OTHER INTERNAL

ELBOW EB BOTH ELBOWS

ES SINGLE ELBOW

FINGER F1 FIRST FINGER

F2 BOTH FIRST FINGERS

F3 SECOND FINGER

F4 BOTH SECOND FINGERS

F5 THIRD FINGER

F6 BOTH THIRD FINGERS

F7 FOURTH FINGER

F8 BOTH FOURTH FINGERS

TOE G1 GREAT TOE

G2 BOTH GREAT TOES

G3 TOE OTHER

G4 TOES OTHER

HEAD, EXTERNAL H1 EYE EXTERNAL

H2 BOTH EYES EXTERNAL

H3 EAR EXTERNAL

H4 BOTH EARS EXTERNAL

HC CHIN

HF FACE

HK NECK/THROAT

HM MOUTH/LIPS

HN NOSE

HS SCALP

KNEE KB BOTH KNEES

KS KNEE

LEG, HIP, ANKLE, LB BOTH LEGS/HIPS/ ANKLES/

BUTTOCKS

BUTTOCK LS SINGLE LEG/HIP/ ANKLE/BUTTOCK

HAND MB BOTH HANDS

MS SINGLE HAND

FOOT PB BOTH FEET

PS SINGLE FOOT

TRUNK, BONES R1 SINGLE COLLAR BONE

R2 BOTH COLLAR BONES

R3 SHOULDER BLADE

R4 BOTH SHOULDER BLADES

RB RIB

RS STERNUM (BREAST BONE)

RV VERTEBRAE (SPINE; DISC)

RZ TRUNK BONES OTHER

SHOULDER SB BOTH SHOULDERS

SS SINGLE SHOULDER

THUMB TB BOTH THUMBS

TS SINGLE THUMB

TRUNK, INTERNAL V1 LUNG, SINGLE

ORGANS V2 LUNGS, BOTH

V3 KIDNEY, SINGLE

V4 KIDNEYS, BOTH

VH HEART

VL LIVER

VR REPRODUCTIVE ORGANS

VS STOMACH

VV INTESTINES

VZ TRUNK, INTERNAL; OTHER

f. NATURE OF INJURY/ILLNESS - Select the most appropriate nature of injury/illness from the list below. This nature of injury/illness shall correspond to the primary body part selected in 5e, above. Enter the nature of injury/illness name on the line and place the corresponding CODE letters in the box provided.

* The injury or condition selected below must be caused by a specific incident or event which occurred during a single work day or shift.

GENERAL NATURE

CATEGORY CODE NATURE OF INJURY NAME

*TRAUMATIC INJURY OR TA AMPUTATION

DISABILITY TB BACK STRAIN

TC CONTUSION; BRUISE; ABRASION

TD DISLOCATION

TF FRACTURE

TH HERNIA

GENERAL NATURE

CATEGORY CODE NATURE OF INJURY NAME

TK CONCUSSION

TL LACERATION, CUT

TP PUNCTURE

TS STRAIN, MULTIPLE

TU BURN, SCALD, SUNBURN

TI TRAUMATIC SKIN DISEASES/

CONDITIONS INCLUDING DERMATITIS

TR TRAUMATIC RESPIRATORY DISEASE

TQ TRAUMATIC FOOD POISONING

TW TRAUMATIC TUBERCULOSIS

TX TRAUMATIC VIROLOGICAL/INFECTIVE/

PARASITIC DISEASE

T1 TRAUMATIC CEREBRAL VASCULAR

CONDITION/STROKE

T2 TRAUMATIC HEARING LOSS

T3 TRAUMATIC HEART CONDITION

T4 TRAUMATIC MENTAL DISORDER,

STRESS; NERVOUS CONDITION

T8 TRAUMATIC INJURY - OTHER (EXCEPT

DISEASE, ILLNESS)

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 9 of 13 Pages

** A nontraumatic physiological harm or loss of capacity produced by systemic infection; continued or repeated stress or strain; exposure to toxins, poisons, fumes, etc.; or other continued and repeated exposures to conditions of the work environment over a long period of time. For practical purposes, an occupational illness/disease or disability is any reported condition which does not meet the definition of traumatic injury or disability as described above.

GENERAL NATURE

CATEGORY CODE NATURE OF INJURY NAME

**NON-TRAUMATIC ILLNESS/DISEASE OR DISABILITY

RESPIRATORY DISEASE RA ASBESTOSIS

RB BRONCHITIS

RE EMPHYSEMA

RP PNEUMOCONIOSIS

RS SILICOSIS

R9 RESPIRATORY DISEASE, OTHER

VIROLOGICAL, INFECTIVE

& PARASITIC DISEASES

VB BRUCELLOSIS

VC COCCIDIOMYCOSIS

VF FOOD POISONING

VH HEPATITIS

VM MALARIA

VS STAPHYLOCOCCUS

VT TUBERCULOSIS

V9 VIROLOGICAL/INFECTIVE/

PARASITIC - OTHER

DISABILITY, DA ARTHRITIS, BURSITIS

OCCUPATIONAL DB BACK STRAIN, BACK SPRAIN

DC CEREBRAL VASCULAR CONDITION;

STROKE

DD ENDEMIC DISEASE (OTHER THAN

CODE TYPES R&S)

DE EFFECT OF ENVIRONMENTAL

CONDITION

DH HEARING LOSS

DK HEART CONDITION

DM MENTAL DISORDER, EMOTIONAL

STRESS, NERVOUS CONDITION

DR RADIATION

DS STRAIN, MULTIPLE

DU ULCER

DV OTHER VASCULAR CONDITIONS

D9 DISABILITY, OTHER

SKIN DISEASE OR

CONDITION

SB BIOLOGICAL

SC CHEMICAL

S9 DERMATITIS, UNCLASSIFIED

g. TYPE AND SOURCE OF INJURY/ILLNESS (CAUSE) - Type and Source Codes are used to describe what caused the incident. The Type Code stands for an ACTION and the Source Code for an OBJECT or SUBSTANCE. Together, they form a brief description of how the incident occurred. Where there are two different sources, code the initiating source of the incident (see example 1, below). Examples:

(1) An employee tripped on carpet and struck his head on a desk. TYPE: 210 (fell on same level) SOURCE: 0110 (walking/working surface).

NOTE: This example would NOT be coded 120 (struck against) and 0140 (furniture).

(2) A Park Ranger contracted dermatitis from contact with poison ivy/oak.

TYPE: 510 (contact) SOURCE: 0920 (plant)

(3) A lock and dam mechanic punctured his finger with a metal sliver while grinding a turbine blade.

TYPE: 410 (punctured by) SOURCE: 0830 (metal)

(4) An employee was driving a government vehicle when it was struck by another vehicle.

TYPE: 800 (traveling in) SOURCE: 0421 (government-owned vehicle, as driver)

NOTE: The Type Code 800, "Traveling In" is different from the other type codes in that its function is not to identify factors contributing to the injury or fatality, but rather to collect data on the type of vehicle the employee was operating or traveling in at the time of the incident.

Select the most appropriate TYPE and SOURCE identifier from the list below and enter the name on the line and the corresponding code in the appropriate box.

CODE TYPE OF INJURY NAME

STRUCK

0110 STRUCK BY

0111 STRUCK BY FALLING OBJECT

0120 STRUCK AGAINST

FELL, SLIPPED, TRIPPED

0210 FELL ON SAME LEVEL

0220 FELL ON DIFFERENT LEVEL

0230 SLIPPED, TRIPPED (NO FALL)

CAUGHT

0310 CAUGHT ON

0320 CAUGHT IN

0330 CAUGHT BETWEEN

PUNCTURED, LACERATED

0410 PUNCTURED BY

0420 CUT BY

0430 STUNG BY

0440 BITTEN BY

CONTACTED

0510 CONTACTED WITH (INJURED PERSON MOVING)

0520 CONTACTED BY (OBJECT WAS MOVING)

EXERTED

0610 LIFTED, STRAINED BY (SINGLE ACTION)

0620 STRESSED BY (REPEATED ACTION)

EXPOSED

0710 INHALED

0720 INGESTED

0730 ABSORBED

0740 EXPOSED TO

0800 TRAVELING IN

CODE SOURCE OF INJURY NAME

0100 BUILDING OR WORKING AREA

0110 WALKING/WORKING SURFACE (FLOOR, STREET,

SIDEWALKS, ETC.)

0120 STAIRS, STEPS

0130 LADDER

0140 FURNITURE, FURNISHINGS, OFFICE EQUIPMENT

0150 BOILER, PRESSURE VESSEL

0160 EQUIPMENT LAYOUT (ERGONOMIC)

0170 WINDOWS, DOORS

0180 ELECTRICITY

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 10 of 13 Pages

0200 ENVIRONMENTAL CONDITION

0210 TEMPERATURE EXTREME (INDOOR)

0220 WEATHER (ICE, RAIN, HEAT, ETC.)

0230 FIRE, FLAME, SMOKE (NOT TOBACCO)

0240 NOISE

0250 RADIATION

0260 LIGHT

0270 VENTILATION

0271 TOBACCO SMOKE

0280 STRESS (EMOTIONAL)

0290 CONFINED SPACE

0300 MACHINE OR TOOL

0310 HAND TOOL (POWERED; SAW, GRINDER, ETC.)

0320 HAND TOOL (NONPOWERED)

0330 MECHANICAL POWER TRANSMISSION APPARATUS

0340 GUARD, SHIELD (FIXED, MOVEABLE, INTERLOCK)

0350 VIDEO DISPLAY TERMINAL

0360 PUMP, COMPRESSOR, AIR PRESSURE TOOL

0370 HEATING EQUIPMENT

0380 WELDING EQUIPMENT

0400 VEHICLE

0411 AS DRIVER OF PRIVATELY OWNED/RENTAL VEHICLE

0412 AS PASSENGER OF PRIVATELY OWNED/RENTAL VEHICLE

0421 DRIVER OF GOVERNMENT VEHICLE

0422 PASSENGER OF…