Monthly Record of Work-Related Injuries/Illnesses & Exposure
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1 age 1 of 5 In accdance with the provisions of EM , ection 01 rogram Management, aragraph 01.D Accident Repting and Recding, sub-paragraphs 01.D.05, you (the rime ) shall provide a monthly recd of all exposure and accident experience incidental to the wk (this includes exposure and accident experience of the rime and its sub-contract(s)). As a minimum, these recds shall include exposure wk hours and a recd occupational injuries and illneses that include the data elements listed below. Definitional criteria f each data element is found in 29 CFR art If the maintenance of OHA 300 Logs are required by OHA, most of this infmation can be obtained from those logs. If data on log provided below is revised after it is submitted to UACE, shall provide a revised rept to the GDA. You must complete the UACE ENG Fm 3394, Rept of Accident Investigation Rept f all recdable accidents. If you're not sure whether a case is recdable, call your local afety and Occupational Health Office f help. UACE Command Name Contract Number roject Title City & tate UACE Office Los Angeles District Freeman's Funny Farm W C-0010 RM Training Contract Litchfield ark, AZ Flagstaff roject Office Lab Classification rime/ubcontract Age Gender No accidents repted Date Employee began wk Date of Injury onset of illness Where the event occured Describe the injury illness From Wk restriction recdable cases Number of On transfer restriction (days) from wk (days) Injury kin Disder Respiraty Condition All other illnesses Exposure Hours Totals: Certification of Recd Month: To Date: 12,899 hours 59,665 hours Name of erson ubmitting Recd: ignature: Kevin Walker Date:
2 age 2 of 5 Freeman's Funny Farm rime ATL, Inc. Materials Testing Aero Automatic prinkler Co. Fire rotection-ystems Aero Construction Co Fencing Affdable Fire & afety Fire rotection-ystems American Fence Fencing Arizona Custom Millwk Cabinetry/Casewk Exposure Hours Number of Number of Number of / s Reptable kin Disder Respiraty 1,359 6, Benham Enterprises, Inc; DBA: Tucson Restaura Bureau of Indian Aff Bureau of Indian Affairs Charles Court Constr pecialities Claridge roducts & Equipment pecialities Commercial Enterprises Insulation-Buildings tructures, Inc Contract Dec, Inc. Ce lab - Albuquer Ceslab tructures - HX Cnell Metro HX Dos, teel Dial Mechanical lumbing 4,258 25, ,259 2, ,
3 age 3 of 5 Exteri ystems FCI Constructs, In rime Falcon Contracting avement Marking Farwest ump lumbing Frank Redmond and As Food ervice Equipment G & G Enterprises Masonry Hark Drilling Howard Electrical Electrical Hufc/Arizona, Inc. J.E.., Inc. pecialities KTI Tile, Inc. Ceramic Tile Kadee Industries, Inc. Kebko Architectural ignage ignage Interi/Exteri L.H Bolander & ons M & K Mechanical HVAC Maggart & Associates Cathodic rotection Mudslingers Nations Gas Technologies lumbing Ncon Industries Exposure Hours Number of Number of Number of / s Reptable kin Disder Respiraty ,488 7, ,380 2, ,
4 age 4 of 5 Nthland urveying urveying Otis Elevat Elevat/Conveying Equip DI est Control est/termite Control artitions & Accessies Toilet artitions/access ena Acoustics Acoustic Ceiling hoenix Fabricats, Inc. Tanks/Tank Covers ower Line Technolog Electric pecial ystems rogressive Roofing Roofing R. E. Nelson Earthwk RTR aving Asphalt aving Rigid Building yste re-engineered Buildings Robert Cohen Co., LL Flo Coverings & H teel teel Joists/Decks an Juan Glass Windows/Glazing ky Design Concepts Windows/Glazing teel D of hoenix Dos, teel unstate Installations, Inc. TAB Technology, Inc. Mechanical Tri-Hurst Construction re-engineered Buildings Exposure Hours Number of Number of Number of / s Reptable kin Disder Respiraty , ,
5 age 5 of 5 UACE ub- VWR International LL Cabinetry/Casewk Western Technologies QC Testing Lab Wholesale Flos Flo Coverings Totals: Exposure Hours Number of Number of Number of / s Reptable kin Disder Respiraty ,899 59,
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Carl Bolander & Sons - Xcel 1,366.50 500.00 183.00 0.00 36.59% 13.39% 0.00 0.00 0.00 0.00 0.00% 0.00% 0.00 0.00 0.00 0.00 0.00% 0.00% 1,366.50 500.00 183.00 0.00 36.59% 13.39% Standard Contracting (t)
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Carl Bolander & Sons - Xcel 1,366.50 500.00 183.00 0.00 36.59% 13.39% 0.00 0.00 0.00 0.00 0.00% 0.00% 0.00 0.00 0.00 0.00 0.00% 0.00% 1,366.50 500.00 183.00 0.00 36.59% 13.39% Standard Contracting (t)
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Carl Bolander & Sons - Xcel 1,366.50 500.00 183.00 0.00 36.59% 13.39% 0.00 0.00 0.00 0.00 0.00% 0.00% 0.00 0.00 0.00 0.00 0.00% 0.00% 1,366.50 500.00 183.00 0.00 36.59% 13.39% Standard Contracting (t)
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