Attachment_9_-_385-43(2).pdf

MVN Form 385-43/2R Proponent: CEMVN-SS September 28, 2009

ACCIDENT PREVENTION PROGRAM

CONTRACTOR ACTIVITY HAZARD ANALYSIS

1. Contract No. & Name of Contractor

2. Contract Name

3. Contract Administrator:

4. Date Prepared

5. Project Location

6. Estimated Start Date

7. PRINCIPAL STEPS

8. POTENTIAL HAZARDS

9. RECOMMENDED CONTROLS

10. EQUIPMENT TO BE USED

11. INSPECTION REQUIREMENTS

12. TRAINING REQUIREMENTS

Contractor/Superintendent or Safety Officer (Signature & Date)

Contractor/Project Manager Or Representative (Signature & Date)

Name of Competent/Qualified Person(s)

MVN Form 385-43/2R Proponent: CEMVN-SS September 28, 2009

INSTRUCTIONS FOR COMPLETION OF CEMVN Form 385-43/2

Item Number

Instructions

1.

Self-explanatory

2.

Self-explanatory

3.

The Area, Resident, Project, or Field Office administering the contract.

4.

Date Hazard Analysis is prepared.

5.

Location of contract or where activity is to be performed.

6.

Estimated start date of the activity being analyzed.

7.

The principal steps of the operation must be identified in sequential order.

8.

Analyze each principal step for potential hazards and identify here.

9.

Specify the controls to mitigate or minimize each potential hazard.

10.

All major pieces of equipment used in each step of the operation must be identified.

11.

List inspection requirements for the work activity and equipment.

12.

List specific training requirements, including hazard communication

13.

The Contract Superintendent or Safety Officer must sign and date analysis.

14.

Contractor/Project Manager must sign and date.

Note: The names of the Competent/Qualified Person(s) required for a particular activity (for example, excavation, scaffolding, fall protection, other activities as specified by OSHA and this manual) shall be identified and included in the AHA. Proof of their competency/qualification shall be submitted to the GDA for acceptance prior to the start of that work activity.