Safety_Paperwork_Attachments.pdf

Modified AHA for Service Contracts

Competent Person (Name, Title, Phone Number, & Signature):

Project Name

Contractor Name

Contract Number

Date

EMERGENCY PHONE NUMBERS AND MEDICAL FACILITY MAP

1. Map with Highlighted Route, Address, and Directions:

2. Emergency Phone Numbers:

Contact Phone Number

SIGNATURE SHEET

Name Signature Date Company

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

3. First Aid/CPR certificates, meeting the requirments of EM 385-1-1 Section 03.A.02, have been submitted for two onsite employees:

a. b.

4. Deficiency Log/Corrective Actions: Date Found Date Corrected

Mishap Reporting and Investigation:

a. is responsible for reporting the exposure data (man-hours worked) to the GDA no later than close of business on the 5th calendar day of the following month.

b. All accidents and near misses will be investigated by the Contractor.

All work-related recordable injuries, illnesses and property damage accidents (excluding on-the-road vehicle accidents), in which the property damage exceeds $5,000.00, will be verbally reported to the GDA within 4 hours of the incident. Serious accidents as described in EM 385-1-1 Section 01.D shall be immediately reported to the GDA.

ENG Form 3394 shall be completed and submitted to the GDA within five working days of the incident.

c. is responsible for completing the accident notifications, investigations, and reports.

Month Year

City State

USACE Office Overseeing Work:

Describe The Case

(B1) (B2) (B3) (C) (D) (F)

Project Title

Using these categories, check ONLY the most serious result for each case:

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.

Contractor Name

USACE PRIME CONTRACTOR

USACE Command

US Army Corps of Engineers

(A) (E)

Contract Number

Classify the case

Check the "injury" column or choose one type of illness:

Identify the person

Enter the number of days the injured or ill worker was:

(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

Away from work (days)

In ju ry

Death

Job transfer or restriction

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

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

Date of injury or onset of illness

Check the "injury" column or choose one type of illness:

Po is on in g

Days away from work

Signature

Certification of Record

Name of Person

Submit. Record

Job Title (e.g., Welder)

(mo./day)

H ea rin g

Lo ss

(M)

Enter the number of days the injured or ill worker was:

FUSRAP

IRP

Year to Date

Ordinance/Expl. Cleanup

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

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)

Environmental Remed.

___ of ___PageEnvironmental Other

FUDS

ENG FORM 3394-1-999 CAN BE FOUND AT THE FOLLOWING LINK: http://www.publications.usace.army.mil/Portals/76/Publications/EngineerForms/ ENG_FORM_3394_1999Mar.pdf?ver=2013-09-08-231303-357