F T

PART I FOR CONTRACTOR USEROICC/FEADCONTRACTOR

ACTIVITY HAZARD ANALYSIS TRANSMITTAL

From: To:

Contract No :

Contract Title :

D

Definable Feature of Work :

Activity Hazard Analysis Dated : Sub-Contractor :

S b C / F R ibl f P f i h W k

Specific Work Activity :

(dd mmm yy)

Date :

Date :Contractor's Project Safety Manager :

Sub-Contractor/ Foreman Responsible for Performing the Work : (dd mmm yy)

I certify that the attached Activity Hazard Analysis complies with all contract safety requirements, including, but not limited to, the USACE Safety and Health Requirements Manual EM-385-1-1.

From: To:

(Signature)

PART II FOR ROICC/FEAD USE

(dd mmm yy)

ROICC/FEAD CONTRACTOR

The attached Activity Hazard Analysis is ACCEPTED. All employees engaged in the activity addressed by this AHA must be trained in the contents of the AHA, and a record made and kept of all attendees of the training, and the AHA and record of attendees must be maintained at the construction site. It is your responsibility to comply with all safety requirements of the contract, including compliance with all requirements

Pl t th f ll i t

The attached Activity Hazard Analysis is NOT ACCEPTED. Revise and resubmit the AHA. The revisions shall address all safety requirements of the contract, including compliance with all requirements of the USACE Safety and Health Requirements Manual EM 385-1-1. The revised AHA must be accepted by the ROICC/FEAD prior to the start of work on the activity addressed by the AHA.

of the USACE Safety and Health Requirements Manual EM 385-1-1.

Date :RIOCC/FEAD Representative :

Please note the following comments:

Date :(Signature)

RIOCC/FEAD Representative : (dd mmm yy)

AHA_TRANSMITTAL_001_KUGAN SEP 2009 www.kugan.com

From : (CONTRACTOR): From : (CONTRACTOR): To : (ROICC/FEAD): To : (ROICC/FEAD): Contract No: Contract Title: Date (dd mmm yy): Sub-Contractor: Definable Feature of Work: Specific Work Activity: S b C / F R ibl f P f i h W k Sub-Contractor/ Foreman Responsible for Performing the Work :: Date (dd mmm yy): Contractor's Project Safety Manager: Date (dd mmm yy): From : (ROICC/FEAD): From : (ROICC/FEAD): To : (CONTRACTOR): To : (CONTRACTOR): Check_Box1: OffCheck_Box3: OffNotes: Notes: Notes: Notes: RIOCC/FEAD Representative: Date (dd mmm yy): PrintButton1: