A2 - WH_CG_EI_FY25-FY29_Mowing_03_SOW_ATT_3_SAW FORM 4 (3).pdf
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- Attached to
- Eagle Island Mowing Services
- Solicitation number
- W912PM24Q0033
About this file
This document is a monthly record of work-related injuries and illnesses, required by the U.S. Army Corps of Engineers (USACE) under Contract Number W912PM24Q0033 for the Eagle Island Mowing Services project. The contractor must provide this record monthly, including exposure work hours and details on any occupational injuries and illnesses incurred by the prime contractor and subcontractors. The record includes information such as the type of work activity, where the incident occurred, the nature of the injury or illness, the number of days the worker was away from work or on job transfer/restriction, and the age and gender of the injured/ill worker. This information must be submitted to the USACE Wilmington District, the agency overseeing the contract.
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Text version
Month Year
City State USACE Office Overseeing Work:
Describe The Case
(B1) (B2) (B3) (C) (D) (F) Enter the number of days the injured or ill worker
Contract Number
Classify the case
Check the "injury" column or choose
Identify the person
(A) (E)
Contractor Name
USACE PRIME CONTRACTOR
USACE Command
US Army Corps of Engineers
Project Title
Using these categories, check ONLY the most
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.
(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
Environmental Remed.
__1 of _1__PageEnvironmental Other
FUDS
Date
Exposure Hours Month
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)
Superfund
TYPE OF WORK ACTIVITY (Choose One):
For Government Use Only
Where the event occurred (e.g. Loading dock north end)Date Employee
Began Work on
Job Covered by Contract
Job Title (e.g., Welder)
(mo./day)
H ea rin g
Lo ss
(M) the injured or ill worker was:
FUSRAP
IRP
Year to Date
Ordinance/Expl. Cleanup
Days away from work
Signature
Certification of Record Name of Person Submit. Record
Date of injury or onset of illness
Check the injury column or choose one type of illness:
Po is on in g
Pr im e or
S ub
(P o r S
Company Name
Al l o th er
Ill ne ss es
On job transfer or restriction (days)
Ag e
G en de r
Other record-able cases
Remained at work
Using these categories, check ONLY the most serious result for each case:
Sk in
D is or de r
R es pi ra to ry
C on di tio n
Away from work (days)
In ju ry
Death
Job transfer or restriction
Record Of Injuries & Illnesses
File details come from the government source that posted it. Updated .