ACCIDENT PREVENTION PLAN

Plan Preparer (Name, Title, Phone Number, & Signature):

Plan Approver (Name, Title, Phone Number, & Signature):

Plan Concurrence (Name, Title, Phone Number, & Signature):

 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.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.
b. Background Information

1. Project Description and Definable Features of Work:

2. Anticipated High Risk Activities:

3. List of Equipment/Machinery to be Used Onsite:

4. Activities Hazard Analysis have been (or will be) submitted to the GDA
for all the Definable Features of Work prior to initiating each phase.

c. Statement of Safety and Health Policy

1. is committed to:

A. The safety, health, and well-being of each and every employee, to

include subcontractors;
B. Requiring all employees to follow all aspects of the APP and
additional company safety programs/policies;
C. Holding all managers and supervisors accountable for the safety
performance and awareness of all employees under their direction;

D. Performing all aspects of this project in accordance with EM 385-1-1

and OSHA regulations;
 E. Maintaining safe and healthful working conditions;
F. Providing all necessary protective equipment to ensure the safety and
health of site employees, subcontractors, and the public;
G. Providing site workers with the information and training required to make
them fully aware of known and suspected hazards that may be
encountered;
H. Encouraging active involvement of employees at all levels, during the
implementation and continuous improvement of the health and safety
program.
I. Additional Safety Policy Information:

3. Contractor Safety Goals and Objectives:

4. Contractor Accident Experience (OSHA 300 forms, or equivalent)

d. Responsibilities and Lines of Authority

1. The lines of authority for this project and at the corporate level are:
(include names and titles)

2. s the Site Safety and Health Officer

. He/she is responsible for enforcing the requirements of this APP
for the duration of the project. The SSHO has the authority to immediately
correct all areas of noncompliance and can stop work
 3. has submitted a 10 Hour OSHA card (or ,
along with their related experience and other qualifications for review.

4. No work will be performed by or any

subcontractors unless the SSHO (or an approved Alternate SSHO) is onsite.

5. If applicable, provide a list of Competent Persons (CPs) and their area

of proficiency: Submit their trainings/qualifications for review.
(Examples: Fall Protection, Excavation/Trenching, Confined Spaces,
Scaffolding, Cranes/Rigging, etc.)

6. Policies and procedures regarding noncompliance with safety

requirements. ‘s disciplinary actions for
violation of safety requirements :

e. Subcontractors and Suppliers:

1. requires its subcontractors to work in a

responsible and safe manner. Subcontractors for this project will be
required to adhere to applicable requirements set forth in the EM
385-
 2. List of Anticipated Subcontractors (Name and Roles):

f. Training:

1. The following Safety and Occupational Health topics will be briefed to

employees on their first day onsite, during the initial site safety
orientation:

2. All employees, including subcontractors, have reviewed this APP

during the safety orientation and have signed the included signature
sheet.

3. The following are mandatory trainings and certifications applicable to

this project: (Examples: Crane Operators, CDL, Diver, SPRAT, etc.)

4. All site personnel have been briefed on the sites emergency response
procedures. This includes but is not limited to:
A. Emergency Communications/Signals:

B. Rally point(s):
 C. Emergency Phone Numbers (Refer to Page 2 of the APP)
D. Locations of emergency equipment:

E. Roles/Responsibilities:

F. A map to closest medical facility is included with the APP.

G. Additional Emergency Information:

5. First Aid/CPR certificates, in accordance with EM 385-1-1 Section

03.A.02, have been submitted for two onsite employees:
a. b.

6. Safety meetings/toolbox talks will be held by the SSHO/Competent

Person: , on a weekly basis or at the
beginning of each new phase of work (whichever is sooner). Minutes
will be documented and will include: attendee’s names, meeting
duration, and topics discussed.

g. Safety and Health Inspections:

1. Daily safety and health inspections will be performed in accordance

with EM 385-1-1, Section 01.A.13. These inspections will be conducted
by the SSHO/Competent Person: . All
inspections must be documented and any deficiencies that cannot be
immediately corrected will be tracked on the deficiency log below, or
equivalent.

2. List any anticipated external inspections (EPA, OSHA, State, other

Federal Agencies, etc.):
 3. Deficiency Log :

h. Mishap Reporting and Investigation:

1. 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.

2. All accidents and near misses 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, 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.

3. is responsible for completing the

accident notifications, investigations, and reports.
i. Plans, Programs, and Procedures:

1. Additional site-specific plans (listed in EM 385-1-1, Appendix A,

Section i) are required to be included as amendments to this APP.
Only the plans applicable to the work being performed are required to
be submitted. A few common plans include but are not limited to:

A. Fall Protection and Prevention

B. Excavation/Trenching
C. Tree Felling and Maintenance
D. Confined Space Entry
E. Rope Access Work
F. Hazardous Energy Control (Lockout/Tagout)
G. Crane/Load Handling Equipment
H. Lead Compliance
I. Asbestos Abatement
J. Hazard Communication
 WEEKLY SAFETY MEETING

Date Held: ________________________

Time: ____________________________

CONTRACTOR: _________________________ Contract No. DACW33-

PERSONNEL PRESENT (check): Contractor ____ Sub. ____ Government ____

SUBJECTS DISCUSSED (check items that were discussed during meeting):

USACE EM385-1-1 ______ (Specific sections: __________________________)

On-site Accident Prevention Plan (or Site Safety and Health Plan) ______
Individual protective equipment (steel-toed boots, safety glasses, etc..) _____
Prevention of slips/falls _____
Back injury/safe lifting techniques _____
Fire prevention _____
First aid _____
Tripping hazards _____
Equipment inspection and maintenance _____
Hoisting equipment, winch and crane safety _____
Ropes, hooks, chains, and slings _____
Water safety _____
Boat safety _____
HAZMAT, Toxic hazards, contaminated sediments, MSDS, respiratory, ventilation _____
Biological hazards (poison ivy, ticks, wasps, mosquitoes etc) ______
Staging, ladders, concrete forms, safety nets, handrails ____
Hand tools, power tools, machinery, chain saws _____
Vehicle operation safety _____
Electrical grounding, temporary wiring, GFCI _____
Lockouts/safe clearance procedures _____
Welding, cutting _____
Excavation hazards/rescue _____
Loose rock/steep slopes _____
Explosives _____
Sanitation and waste disposal _____
Clean-up, trash _____

Other safety issues of concern specific to contract that was discussed during meeting:

All persons attending meeting the meeting must sign below or on the back of the form.

Contractor Representative Signature ____________________________ Date: _______

CE Inspector/QA (if present at meeting) __________________________ Date: __________

1
 REPORT NO. EROC CODE UNITED STATES ARMY CORPS OF ENGINEERS
REQUIREMENT
(For safety ACCIDENT INVESTIGATION REPORT CONTROL SYMBOL:
staff only) For use of this form, see Help Menu and USACE Supplement to AR 385-40 CEEC-S-8 (R2)
The proponent agency is CESO
1. ACCIDENT CLASSIFICATION

PERSONNEL CLASSIFICATION INJURY/ILLNESS/FATAL PROPERTY DAMAGE MOTOR VEHICLE INVOLVED DIVING

GOVERNMENT
FIRE INVOLVED OTHER
CIVILIAN MILITARY

CONTRACTOR FIRE INVOLVED OTHER

PUBLIC FATAL OTHER

2. PERSONAL DATA

a. NAME (Last, First MI.) b. AGE c. SEX d. SOCIAL SECURITY NUMBER e. GRADE
MALE FEMALE

f. JOB SERIES/TITLE g. DUTY STATUS AT TIME OF ACCIDENT h. EMPLOYMENT STATUS AT TIME OF ACCIDENT
ARMY ACTIVE ARMY RESERVE VOLUNTEER

ON DUTY TDY PERMANENT FOREIGN NATIONAL SEASONAL

TEMPORARY STUDENT

OFF DUTY OTHER (Specify)

3. GENERAL INFORMATION

a. DATE OF ACCIDENT b. TIME OF ACCIDENT c. EXACT LOCATION OF ACCIDENT d. CONTRACTOR'S NAME

(YYYYMMDD) (Military Time)
(1) PRIME
hrs.
e. CONTRACT NUMBER f. TYPE OF CONTRACT g. HAZARDOUS/TOXIC WASTE
CONSTRUCTION SERVICE ACTIVITY
SUPERFUND DERP (2) SUBCONTRACTOR
CIVIL WORKS MILITARY A/E DREDGE
IRP OTHER (Specify)
OTHER (Specify) OTHER (Specify)

4. CONSTRUCTION ACTIVITIES ONLY (Fill in line and corresponding code number in box from list - see help menu)
a. CONSTRUCTION ACTIVITY (CODE) b. TYPE OF CONSTRUCTION EQUIPMENT (CODE)

# #

5. INJURY/ILLNESS INFORMATION (Include name on line and corresponding code number in box for items e, f & g - see help menu)
a. SEVERITY OF ILLNESS/INJURY (CODE) b. ESTIMATED c. ESTIMATED DAYS d. ESTIMATED DAYS
DAYS LOST HOSPITALIZED RESTRICTED DUTY
#

e. BODY PART AFFECTED (CODE) g. TYPE AND SOURCE OF INJURY/ILLNESS (CODE)

PRIMARY # TYPE #
(CODE)
SECONDARY
# (CODE)
f. NATURE OF ILLNESS / INJURY (CODE) SOURCE #

6. PUBLIC FATALITY (Fill in line and correspondence code number in box - see help menu)
a. ACTIVITY AT TIME OF ACCIDENT (CODE) b. PERSONAL FLOTATION DEVICE USED?

# YES NO N/A

ENG FORM 3394, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 1 of 13 Pages
7. MOTOR VEHICLE ACCIDENT

a. TYPE OF VEHICLE b. TYPE OF COLLISION

c. SEAT BELTS USED NOT USED NOT APPLICABLE
PICKUP/VAN AUTOMOBILE SIDE SWIPE HEAD ON REAR END
(1) FRONT SEAT
TRUCK OTHER (Specify) BROADSIDE ROLL OVER BACKING

OTHER (Specify)
(2) REAR SEAT

8. PROPERTY MATERIAL INVOLVED

a. NAME OF ITEM b. OWNERSHIP c. AMOUNT OF DAMAGE

(1)

(2)

(3)

9. VESSEL/FLOATING PLANT ACCIDENT (Fill in line and correspondence code number in box from list - see help menu)
a. ACTIVITY AT TIME OF ACCIDENT (CODE) a. ACTIVITY AT TIME OF ACCIDENT (CODE)

# #

10. ACCIDENT DESCRIPTION (Use additional paper, if necessary, see attached page 4.)

11. CAUSAL FACTOR(s) (Read instructions before completing)

a. (Explain YES answers in item 13) YES NO

DESIGN: Was design of facility, workplace or equipment a factor?

INSPECTION/MAINTENANCE: Were inspection & maintenance procedures a factor?

PERSON'S PHYSICAL CONDITION: In your opinion, was the physical condition of the person a factor?

OPERATING PROCEDURES: Were operating procedures a factor?

JOB PRACTICES: Were any job safety/health practices not followed when the accident occurred?

HUMAN FACTORS: Did any human factors such as, size or strength of person, etc., contribute to accident?

ENVIRONMENTAL FACTORS: Did heat, cold, dust, sun, glare, etc., contribute to the accident?

CHEMICAL AND PHYSICAL AGENT FACTORS: Did exposure to chemical agents, such as dust, fumes, mists, vapors or physical agents, such
as, noise, radiation, etc., contribute to accident?

OFFICE FACTORS: Did office setting such as, lifting office furniture, carrying, stooping, etc., contribute to the accident?

SUPPORT FACTORS: Were inappropriate tools/resources provided to properly perform the activity/task?

PERSONAL PROTECTIVE EQUIPMENT: Did the improper selection, use or maintenance of personal protective equipment contribute to the
accident?

DRUGS/ALCOHOL: In your opinion, was drugs or alcohol a factor to the accident?

b. WAS A WRITTEN JOB/ACTIVITY HAZARD ANALYSIS COMPLETED FOR TASK BEING PERFORMED AT TIME OF ACCIDENT? (If yes,
attach a copy.)

12. TRAINING
a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK? b. TYPE OF TRAINING c. DATE OF MOST RECENT FORMAL
TRAINING (YYYYMMDD)
YES NO CLASSROOM ON JOB

13. FULLY EXPLAIN WHAT ALLOWED OR CAUSED THE ACCIDENT; INCLUDE DIRECT AND INDIRECT CAUSES (See instruction for definition of direct and
indirect causes.) (Use additional paper, if necessary)

a. DIRECT CAUSE(s) (Attach additional sheets as needed, See page 4)

b. INDIRECT CAUSE(s) (Attach additional sheets as needed, See page 5)

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 2 of 13
14. ACTION(s) TAKEN, ANTICIPATED OR RECOMMENDED TO ELIMINATE CAUSE(s)

DESCRIBE FULLY (Attach additional sheets as necessary, See page 5)

15. DATES FOR ACTIONS IDENTIFIED IN BLOCK 14.

a. BEGINNING (YYYYMMDD) b. ANTICIPATED COMPLETION (YYYYMMDD)

c. DATE SIGNED d. TITLE OF SUPERVISOR COMPLETING REPORT e. CORPS SIGNATURE, SUPERVISOR COMPLETING REPORT
(YYYYMMDD)

c. DATE SIGNED d. TITLE OF SUPERVISOR COMPLETING REPORT e. CONTRACTOR SIGNATURE, SUPERVISOR COMPLETING REPORT
(YYYYMMDD)

f. ORGANIZATION IDENTIFIER (Division, Branch, Section, etc.,) g. OFFICE SYMBOL

16. MANAGEMENT REVIEW (1st)

a. CONCUR b. NONCONCUR c. COMMENTS

DATE (YYYYMMDD) TITLE SIGNATURE

17. MANAGEMENT REVIEW (2nd - Chief Operations, Construction, Engineering, etc.,)

a. CONCUR b. NONCONCUR c. COMMENTS

DATE (YYYYMMDD) TITLE SIGNATURE

18. SAFETY AND OCCUPATIONAL HEALTH OFFICE REVIEW

a. CONCUR b. NONCONCUR c. ADDITIONAL ACTIONS/COMMENTS

DATE (YYYYMMDD) TITLE SIGNATURE

19. COMMAND APPROVAL

COMMENTS

DATE (YYYYMMDD) COMMANDER SIGNATURE

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 3 of 13 Pages
10. ACCIDENT DESCRIPTION (Continuation)

13a. DIRECT CAUSE(s) (Continuation)

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 4 of 13 Pages
13b. INDIRECT CAUSE(s) (Continuation)

14. ACTION(s) TAKEN, ANTICIPATED, OR RECOMMENDED TO ELIMINATE CAUSE(s) (Continuation)

ENG FORM 3394C, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 5 of 13 Pages
GENERAL. Complete a separate report for each person who was injured, caused, or contributed to the accident (excluding uninjured personnel and witnesses).
Use of this form for reporting USACE employee first-aid type injuries not submitted to the Office of Workers' Compensation Programs (OWCP) shall be at the
discretion of the FOA commander. Please type or print legibly. Appropriate items shall be marked with an "X" in box(es). If additional space is needed, provide the
information on a separate sheet and attach to the completed form. Ensure that these instructions are forwarded with the completed report to the designated
management reviewers indicated in sections 16 and 17.

INSTRUCTIONS FOR SECTION 1 - ACCIDENT CLASSIFICATION

(Mark All Boxes That Are Applicable)

a. GOVERNMENT. Mark "CIVILIAN" box if accident involved government civilian employee; mark "MILITARY" box if accident involved U.S. military personnel.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in any government civilian employee injury, illness, or fatality that requires the submission of OWCP
Forms CA-1 (injury), CA-2 (illness) or CA-6 (fatality) to OWCP; mark if accident resulted in military personnel lost-time or fatal injury or illness.

(2) PROPERTY DAMAGE - Mark the appropriate box if accident resulted in any damage of $1000 or more to government property (including motor vehicles).

(3) VEHICLE INVOLVED - Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are
marked.

(4) DIVING ACTIVITY - Mark if the accident involved an in-house USACE diving activity.

b. CONTRACTOR.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in any contractor lost-time injury/illness or fatality.

(2) PROPERTY DAMAGE - Mark the appropriate box if accident resulted in any damage of $1000 or more to contractor property (including motor vehicles).

(3) VEHICLE INVOLVED - Mark if accident involved a motor vehicle, regardless of whether "INJURY/ILLNESS/FATALITY" or "PROPERTY DAMAGE" are
marked.

(4) DIVING ACTIVITY - Mark if the accident involved a USACE Contractor diving activity.

c. PUBLIC.

(1) INJURY/ILLNESS/FATALITY - Mark if accident resulted in public fatality or permanent total disability. (The "OTHER" box will be marked when requested by
the FOA to report an unusual non-fatal public accident that could result in claims against the government or as otherwise directed by the FOA Commander).

(2) VOID SPACE - Make no entry.

(3) VEHICLE INVOLVED - Mark if accident resulted in a fatality to a member of the public and involved a motor vehicle, regardless of whether "INJURY/lLLNESS/
FATALlTY" is marked.

(4) VOID SPACE - Make no entry.

INSTRUCTIONS FOR SECTION 2 - PERSONAL DATA

a. NAME - (MANDATORY FOR GOVERNMENT ACCIDENTS. OPTIONAL AT THE DISCRETION OF THE FOA COMMANDER FOR CONTRACTOR AND
PUBLIC ACCIDENTS). Enter last name, first name, middle initial of person involved.

b. AGE - Enter age.

c. SEX - Mark appropriate box.

d. SOCIAL SECURITY NUMBER - (FOR GOVERNMENT PERSONNEL ONLY) Enter the social security number (or other personal identification number if no
social security number issued).

e. GRADE - (FOR GOVERNMENT PERSONNEL ONLY) Enter pay grade. Example: 0-6; E-7; WG-8; WS-12; GS-11; etc.

f. JOB SERIES/TlTLE - For government civilian employees enter the pay plan, full series number, and job title, e.g., GS-O810/Civil Engineer. For military
personnel enter the primary military occupational specialty (PMOS), e.g., 15A30 or 11G50. For contractor employees enter the job title assigned to the injured
person, e.g., carpenter, laborer, surveyor, etc.

g. DUTY STATUS - Mark the appropriate box.

(1) ON DUTY - Person was at duty station during duty hours or person was away from duty station during duty hours but on official business at time of the
accident.

(2) TDY - Person was on official business, away from the duty station and with travel orders at time of accident. Line-of-duty investigation required.

(3) OFF DUTY - Person was not on official business at time of accident.

h. EMPLOYMENT STATUS - (FOR GOVERNMENT PERSONNEL ONLY) Mark the most appropriate box. If "OTHER" is marked, specify the employment status
of the person.

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 6 of 13 Pages
INSTRUCTION FOR SECTION 3 - GENERAL INFORMATION

a. DATE OF ACCIDENT - Enter the month, day, and year of accident.

b. TIME OF ACCIDENT - Enter the local time of accident in military time. Example: 1430 hrs (not 2:30 p.m.).

c. EXACT LOCATION OF ACCIDENT - Enter facts needed to locate the accident scene, (installation/project name, building number, street, direction and distance
from closest landmark, etc.).

d. CONTRACTOR NAME

(1) PRIME - Enter the exact name (title of firm) of the prime contractor.

(2) SUBCONTRACTOR - Enter the name of any subcontractor involved in the accident.

e. CONTRACT NUMBER - Mark the appropriate box to identify if contract is civil works, military, or other: if "OTHER" is marked, specify contract appropriation on
line provided. Enter complete contract number of prime contract, e.g., DACW 09-85-C-0100.

f. TYPE OF CONTRACT - Mark appropriate box. A/E means architect/engineer. If "OTHER" is marked, specify type of contract on line provided.

g. HAZARDOUS/TOXIC WASTE ACTIVITY (HTW) - Mark the box to identify the HTW activity being performed at the time of the accident. For Superfund, DERP,
and Installation Restoration Program (IRP) HTW activities include accidents that occurred during inventory, predesign, design, and construction. For the
purpose of accident reporting, DERP Formerly Used DoD Site (FUDS) activities and IRP activities will be treated separately. For Civil Works O&M HTW
activities mark the "OTHER" box.

INSTRUCTIONS FOR SECTION 4 - CONSTRUCTION ACTIVITIES

a. CONSTRUCTION ACTIVITY - Select the most appropriate construction activity being performed at time of accident from the list below. Enter the activity name
and place the corresponding code number identified in the box.

CONSTRUCTION ACTIVITY LIST 13. CARPENTRY

14. ELECTRICAL
1. MOBILIZATION 15. SCAFFOLDING/ACCESS
2. SITE PREPARATION 16. MECHANICAL
3. EXCAVATION/TRENCHING 17. PAINTING
4. GRADING (EARTHWORK) 18. EOUIPMENT/MAINTENANCE
5. PIPING/UTILITIES 19. TUNNELING
6. FOUNDATION 20. WAREHOUSING/STORAGE
7. FORMING 21. PAVING
8. CONCRETE PLACEMENT 22. FENCING
9. STEEL ERECTION 23. SIGNING
10. ROOFING 24. LANDSCAPING/IRRIGATION
11. FRAMING 25. INSULATION
12. MASONRY 26. DEMOLITION

b. TYPE OF CONSTRUCTION EQUIPMENT - Select the equipment involved in the accident from the list below. Enter the name and place the corresponding
code number identified in the box. If equipment is not included below, use code 24, "OTHER", and write in specific type of equipment.
CONSTRUCTION EQUIPMENT 12. DUMP TRUCK (HIGHWAY)
13. DUMP TRUCK (OFF HIGHWAY)
1. GRADER 14. TRUCK (OTHER)
2. DRAGLINE 15. FORKLIFT
3. CRANE (ON VESSEL/BARGE) 16. BACKHOE
4. CRANE (TRACKED) 17. FRONT-END LOADER
5. CRANE (RUBBER TIRE) 18. PILE DRIVER
6. CRANE (VEHICLE MOUNTED) 19. TRACTOR (UTILITY)
7. CRANE (TOWER) 20. MANLIFT
8. SHOVEL 21. DOZER
9. SCRAPER 22. DRILL RIG
10. PUMP TRUCK (CONCRETE) 23. COMPACTOR/VIBRATORY ROLLER
11. TRUCK (CONCRETE/TRANSIT MIXER) 24. OTHER

INSTRUCTIONS FOR SECTION 5 - INJURY/ILLNESS INFORMATION

a. SEVERITY OF INJURY/ILLNESS - Reference paragraph 2-10 of USACE Supplement 1 to AR 385-40 and enter code and description from list below.

NOI NO INJURY
FAT FATALITY
PTL PERMANENT TOTAL DISABILITY
PPR PERMANENT PARTIAL DISABILITY
LWD LOST WORKDAY CASE INVOLVING DAYS AWAY FROM WORK
NLW RECORDABLE CASE WITHOUT LOST WORKDAYS
RFA RECORDABLE FIRST AID CASE
NRI NON-RECORDABLE INJURY

b. ESTIMATED DAYS LOST - Enter the estimated number of workdays the person will lose from work.

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 7 of 13 Pages
c. ESTIMATED DAYS HOSPITALIZED - Enter the estimated number of workdays the person will be hospitalized.

d. ESTIMATED DAYS RESTRICTED DUTY - Enter the estimated number of workdays the person, as a result of the accident, will not be able to perform all of
their regular duties.

e. BODY PART AFFECTED - Select the most appropriate primary and when applicable, secondary body part affected from the list below. Enter body part name
on line and place the corresponding code letters identifying that body part in the box.
GENERAL BODY AREA CODE BODY PART NAME HEAD, EXTERNAL H1 EYE EXTERNAL
H2 BOTH EYES EXTERNAL
ARM/WRIST AB ARM AND WRIST H3 EAR EXTERNAL
AS ARM OR WRIST H4 BOTH EARS EXTERNAL
HC CHIN
TRUNK, EXTERNAL B1 SINGLE BREAST HF FACE
MUSCULATURE B2 BOTH BREASTS HK NECK/THROAT
B3 SINGLE TESTICLE HM MOUTH/LIPS
B4 BOTH TESTICLES HN NOSE
BA ABDOMEN HS SCALP
BC CHEST
BL LOWER BACK KNEE KB BOTH KNEES
BP PENIS KS KNEE
BS SIDE LEG, HIP, ANKLE, LB BOTH LEGS/HIPS/ ANKLES/
BU UPPER BACK BUTTOCKS
BW WAIST BUTTOCK LS SINGLE LEG/HIP/ ANKLE/BUTTOCK
BZ TRUNK OTHER
HAND MB BOTH HANDS
HEAD, INTERNAL C1 SINGLE EAR INTERNAL MS SINGLE HAND
C2 BOTH EARS INTERNAL
C3 SINGLE EYE INTERNAL FOOT PB BOTH FEET
C4 BOTH EYES INTERNAL PS SINGLE FOOT
CB BRAIN
CC CRANIAL BONES TRUNK, BONES R1 SINGLE COLLAR BONE
CD TEETH R2 BOTH COLLAR BONES
CJ JAW R3 SHOULDER BLADE
CL THROAT, LARYNX R4 BOTH SHOULDER BLADES
CM MOUTH RB RIB
CN NOSE RS STERNUM (BREAST BONE)
CR THROAT, OTHER RV VERTEBRAE (SPINE; DISC)
CT TONGUE RZ TRUNK BONES OTHER
CZ HEAD OTHER INTERNAL
SHOULDER SB BOTH SHOULDERS
ELBOW EB BOTH ELBOWS SS SINGLE SHOULDER
ES SINGLE ELBOW
THUMB TB BOTH THUMBS
FINGER F1 FIRST FINGER TS SINGLE THUMB
F2 BOTH FIRST FINGERS
F3 SECOND FINGER TRUNK, INTERNAL V1 LUNG, SINGLE
F4 BOTH SECOND FINGERS ORGANS V2 LUNGS, BOTH
F5 THIRD FINGER V3 KIDNEY, SINGLE
F6 BOTH THIRD FINGERS V4 KIDNEYS, BOTH
F7 FOURTH FINGER VH HEART
F8 BOTH FOURTH FINGERS VL LIVER
TOE G1 GREAT TOE VR REPRODUCTIVE ORGANS
G2 BOTH GREAT TOES VS STOMACH
G3 TOE OTHER VV INTESTINES
G4 TOES OTHER VZ TRUNK, INTERNAL; OTHER

f. NATURE OF INJURY/ILLNESS - Select the most appropriate nature of injury/illness from the list below. This nature of injury/illness shall correspond to the
primary body part selected in 5e, above. Enter the nature of injury/illness name on the line and place the corresponding CODE letters in the box provided.
* The injury or condition selected below must be caused by a specific incident or event which occurred during a single work day or shift.
GENERAL NATURE TU BURN, SCALD, SUNBURN
CATEGORY CODE NATURE OF INJURY NAME TI TRAUMATIC SKIN DISEASES/
CONDITIONS INCLUDING DERMATITIS
*TRAUMATIC INJURY OR TA AMPUTATION TR TRAUMATIC RESPIRATORY DISEASE
DISABILITY TB BACK STRAIN TQ TRAUMATIC FOOD POISONING
TC CONTUSION; BRUISE; ABRASION TW TRAUMATIC TUBERCULOSIS
TD DISLOCATION TX TRAUMATIC VIROLOGICAL/INFECTIVE/
TF FRACTURE PARASITIC DISEASE
TH HERNIA T1 TRAUMATIC CEREBRAL VASCULAR
GENERAL NATURE CONDITION/STROKE
CATEGORY CODE NATURE OF INJURY NAME T2 TRAUMATIC HEARING LOSS
T3 TRAUMATIC HEART CONDITION
TK CONCUSSION T4 TRAUMATIC MENTAL DISORDER,
TL LACERATION, CUT STRESS; NERVOUS CONDITION
TP PUNCTURE T8 TRAUMATIC INJURY - OTHER (EXCEPT
TS STRAIN, MULTIPLE DISEASE, ILLNESS)

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 8 of 13 Pages
** A nontraumatic physiological harm or loss of capacity produced by systemic infection; continued or repeated stress or strain; exposure to toxins, poisons,
fumes, etc.; or other continued and repeated exposures to conditions of the work environment over a long period of time. For practical purposes, an occupational
illness/disease or disability is any reported condition which does not meet the definition of traumatic injury or disability as described above.

GENERAL NATURE
CATEGORY CODE NATURE OF INJURY NAME

**NON-TRAUMATIC ILLNESS/DISEASE OR DISABILITY

RESPIRATORY DISEASE RA ASBESTOSIS DD ENDEMIC DISEASE (OTHER THAN
RB BRONCHITIS CODE TYPES R&S)
RE EMPHYSEMA DE EFFECT OF ENVIRONMENTAL
RP PNEUMOCONIOSIS CONDITION
RS SILICOSIS DH HEARING LOSS
R9 RESPIRATORY DISEASE, OTHER DK HEART CONDITION
VIROLOGICAL, INFECTIVE DM MENTAL DISORDER, EMOTIONAL
& PARASITIC DISEASES STRESS, NERVOUS CONDITION
VB BRUCELLOSIS DR RADIATION
VC COCCIDIOMYCOSIS DS STRAIN, MULTIPLE
VF FOOD POISONING DU ULCER
VH HEPATITIS DV OTHER VASCULAR CONDITIONS
VM MALARIA D9 DISABILITY, OTHER
VS STAPHYLOCOCCUS
VT TUBERCULOSIS SKIN DISEASE OR
V9 VIROLOGICAL/INFECTIVE/ CONDITION
PARASITIC - OTHER SB BIOLOGICAL
DISABILITY, DA ARTHRITIS, BURSITIS SC CHEMICAL
OCCUPATIONAL DB BACK STRAIN, BACK SPRAIN S9 DERMATITIS, UNCLASSIFIED
DC CEREBRAL VASCULAR CONDITION;
STROKE

g. TYPE AND SOURCE OF INJURY/ILLNESS (CAUSE) - Type and Source Codes are used to describe what caused the incident. The Type Code stands for an
ACTION and the Source Code for an OBJECT or SUBSTANCE. Together, they form a brief description of how the incident occurred. Where there are two
different sources, code the initiating source of the incident (see example 1, below). Examples:

(1) An employee tripped on carpet and struck his head on a desk. TYPE: 210 (fell on same level) SOURCE: 0110 (walking/working surface).

NOTE: This example would NOT be coded 120 (struck against) and 0140 (furniture).

(2) A Park Ranger contracted dermatitis from contact with poison ivy/oak.

TYPE: 510 (contact) SOURCE: 0920 (plant)

(3) A lock and dam mechanic punctured his finger with a metal sliver while grinding a turbine blade.

TYPE: 410 (punctured by) SOURCE: 0830 (metal)

(4) An employee was driving a government vehicle when it was struck by another vehicle.

TYPE: 800 (traveling in) SOURCE: 0421 (government-owned vehicle, as driver)

NOTE: The Type Code 800, "Traveling In" is different from the other type codes in that its function is not to identify factors contributing to the injury or fatality, but
rather to collect data on the type of vehicle the employee was operating or traveling in at the time of the incident.

Select the most appropriate TYPE and SOURCE identifier from the list below and enter the name on the line and the corresponding code in the appropriate box.
CODE TYPE OF INJURY NAME EXERTED
0610 LIFTED, STRAINED BY (SINGLE ACTION)
STRUCK 0620 STRESSED BY (REPEATED ACTION)
0110 STRUCK BY EXPOSED
0111 STRUCK BY FALLING OBJECT 0710 INHALED
0120 STRUCK AGAINST 0720 INGESTED
FELL, SLIPPED, TRIPPED 0730 ABSORBED
0210 FELL ON SAME LEVEL 0740 EXPOSED TO
0220 FELL ON DIFFERENT LEVEL 0800 TRAVELING IN
0230 SLIPPED, TRIPPED (NO FALL)
CAUGHT CODE SOURCE OF INJURY NAME
0310 CAUGHT ON
0320 CAUGHT IN 0100 BUILDING OR WORKING AREA
0330 CAUGHT BETWEEN 0110 WALKING/WORKING SURFACE (FLOOR, STREET,
PUNCTURED, LACERATED SIDEWALKS, ETC.)
0410 PUNCTURED BY 0120 STAIRS, STEPS
0420 CUT BY 0130 LADDER
0430 STUNG BY 0140 FURNITURE, FURNISHINGS, OFFICE EQUIPMENT
0440 BITTEN BY 0150 BOILER, PRESSURE VESSEL
CONTACTED 0160 EQUIPMENT LAYOUT (ERGONOMIC)
0510 CONTACTED WITH (INJURED PERSON MOVING) 0170 WINDOWS, DOORS
0520 CONTACTED BY (OBJECT WAS MOVING) 0180 ELECTRICITY

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0200 ENVIRONMENTAL CONDITION 0631 CARBON MONOXIDE
0210 TEMPERATURE EXTREME (INDOOR) 0640 MIST, STEAM, VAPOR, FUME
0220 WEATHER (ICE, RAIN, HEAT, ETC.) 0641 WELDING FUMES
0230 FIRE, FLAME, SMOKE (NOT TOBACCO) 0650 PARTICLES (UNIDENTIFIED)
0240 NOISE 0700 CHEMICAL, PLASTIC, ETC.
0250 RADIATION 0711 DRY CHEMICAL - CORROSIVE
0260 LIGHT 0712 DRY CHEMICAL - TOXIC
0270 VENTILATION 0713 DRY CHEMICAL - EXPLOSIVE
0271 TOBACCO SMOKE 0714 DRY CHEMICAL FLAMMABLE
0280 STRESS (EMOTIONAL) 0721 LIQUID CHEMICAL - CORROSIVE
0290 CONFINED SPACE 0722 LIQUID CHEMICAL - TOXIC
0300 MACHINE OR TOOL 0723 LIQUID CHEMICAL - EXPLOSIVE
0310 HAND TOOL (POWERED; SAW, GRINDER, ETC.) 0724 LIQUID CHEMICAL - FLAMMABLE
0320 HAND TOOL (NONPOWERED) 0730 PLASTIC
0330 MECHANICAL POWER TRANSMISSION APPARATUS 0740 WATER
0340 GUARD, SHIELD (FIXED, MOVEABLE, INTERLOCK) 0750 MEDICINE
0350 VIDEO DISPLAY TERMINAL 0800 INAMINATE OBJECT
0360 PUMP, COMPRESSOR, AIR PRESSURE TOOL 0810 BOX, BARREL, ETC.
0370 HEATING EQUIPMENT 0820 PAPER
0380 WELDING EQUIPMENT 0830 METAL ITEM, MINERAL
0400 VEHICLE 0831 NEEDLE
0411 AS DRIVER OF PRIVATELY OWNED/RENTAL VEHICLE 0840 GLASS
0412 AS PASSENGER OF PRIVATELY OWNED/RENTAL VEHICLE 0850 SCRAP, TRASH
0421 DRIVER OF GOVERNMENT VEHICLE 0860 WOOD
0422 PASSENGER OF GOVERNMENT VEHICLE 0870 FOOD
0430 COMMON CARRIER (AIRLINE, BUS, ETC.) 0880 CLOTHING, APPAREL, SHOES
0440 AIRCRAFT (NOT COMMERCIAL) 0900 ANIMATE OBJECT
0450 BOAT, SHIP, BARGE 0911 DOG
0500 MATERIAL HANDLING EQUIPMENT 0912 OTHER ANIMAL
0510 EARTHMOVER (TRACTOR, BACKHOE, ETC.) 0920 PLANT
0520 CONVEYOR (FOR MATERIAL AND EQUIPMENT) 0930 INSECT
0530 ELEVATOR, ESCALATOR, PERSONNEL HOIST 0940 HUMAN (VIOLENCE)
0540 HOIST, SLING CHAIN, JACK 0950 HUMAN (COMMUNICABLE DISEASE)
0550 CRANE 0960 BACTERIA, VIRUS (NOT HUMAN CONTACT)
0551 FORKLIFT 1000 PERSONAL PROTECTIVE EQUIPMENT
0560 HANDTRUCK, DOLLY 1010 PROTECTIVE CLOTHING, SHOES, GLASSES,
0600 DUST, VAPOR, ETC. GOGGLES
0610 DUST (SILICA, COAL, ETC.) 1020 RESPIRATOR, MASK
0620 FIBERS 1021 DIVING EQUIPMENT
0621 ASBESTOS 1030 SAFETY BELT, HARNESS
0630 GASES 1040 PARACHUTE
INSTRUCTIONS FOR SECTION 6 - PUBLIC FATALITY

a. ACTIVITY AT TIME OF ACCIDENT - Select the activity being performed at the time of the accident from the list below. Enter the activity name on the line and
the corresponding number in the box. If the activity performed is not identified on the list, select from the most appropriate primary activity area (water related,
non-water related or other activity), the code number for "Other", and write in the activity being performed at the time of the accident.
WATER RELATED RECREATION 19. Camping/picnicking unauthorized area
20. Guided tours
1. Sailing 21. Hunting
2. Boating-powered 22. Playground equipment
3. Boating-unpowered 23. Sports/summer (baseball, football, etc.)
4. Water skiing 24. Sports/winter (skiing, sledding, snowmobiling etc.)
5. Fishing from boat 25. Cycling (bicycle, motorcycle, scooter)
6. Fishing from bank dock or pier 26. Gliding
7. Fishing while wading 27. Parachuting
8. Swimming/supervised area 28. Other non-water related
9. Swimming/designated area
10. Swimming/other area OTHER ACTIVITIES
11. Underwater activities (skin diving, scuba, etc.)
12. Wading 29. Unlawful acts (fights, riots, vandalism, etc.)
13. Attempted rescue 30. Food preparation/serving
14. Hunting from boat 31. Food consumption
15. Other 32. Housekeeping
33. Sleeping
NON-WATER RELATED RECREATION 34. Pedestrian struck by vehicle
35. Pedestrian other acts
16. Hiking and walking 36. Suicide
17. Climbing (general) 37. "Other" activities
18. Camping/picnicking authorized area
b. PERSONAL FLOTATION DEVICE USED - If fatality was water-related was the victim wearing a person flotation device? Mark the appropriate box.

INSTRUCTIONS FOR SECTION 7 - MOTOR VEHICLE ACCIDENT

a. TYPE OF VEHICLE - Mark appropriate box for each vehicle involved. If more than one vehicle of the same type is involved, mark both halves of the
appropriate box. USACE vehicle(s) involved shall be marked in left half of appropriate box.

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 10 of 13 Pages
b. TYPE OF COLLISION - Mark appropriate box.

c. SEAT BELT - Mark appropriate box.

INSTRUCTIONS FOR SECTION 8 - PROPERTY/MATERIAL INVOLVED

a. NAME OF ITEM - Describe all property involved in accident. Property/material involved means material which is damaged or whose use or misuse contributed
to the accident. Include the name, type, model; also include the National Stock Number (NSN) whenever applicable.

b. OWNERSHIP - Enter ownership for each item listed. (Enter one of the following: USACE; OTHER GOVERNMENT; CONTRACTOR; PRIVATE)

c. $ AMOUNT OF DAMAGE - Enter the total estimated dollar amount of damage (parts and labor), if any.

INSTRUCTIONS FOR SECTION 9 - VESSEL/FLOATING PLANT ACCIDENT

a. TYPE OF VESSEL/FLOATING PLANT - Select the most appropriate vessel/floating plant from list below. Enter name and place corresponding number in box.
If item is not listed below, enter item number for "OTHER" and write in specific type of vessel floating plant.

VESSEL/FLOATING PLANTS b. COLLISION/MISHAP - Select from the list below the object(s) that
contributed to the accident or were damaged in the accident.
1. ROW BOAT
2. SAIL BOAT COLLISION/MISHAP
3. MOTOR BOAT
4. BARGE 1. COLLISION W/OTHER VESSEL
5. DREDGE/HOPPER 2. UPPER GUIDE WALL
6. DREDGE/SIDE CASTING 3. UPPER LOCK GATES
7. DREDGE/DIPPER 4. LOCK WALL
8. DREDGE/CLAMSHELL, BUCKET 5. LOWER LOCK GATES
9. DREDGE/PIPE LINE 6. LOWER GUIDE WALL
10. DREDGE/DUST PAN 7. HAULAGE UNIT
11. TUG BOAT 8. BREAKING TOW
12. OTHER 9. TOW BREAKING UP
10. SWEPT DOWN 0N DAM
11. BUOY/DOLPHIN/CELL
12. WHARF OR DOCK
13. OTHER

INSTRUCTIONS FOR SECTION 10 - ACCIDENT DESCRIPTION

DESCRIBE ACCIDENT - Fully describe the accident. Give the sequence of events that describe what happened leading up to and including the accident. Fully
identify personnel and equipment involved and their role(s) in the accident. Ensure that relationships between personnel and equipment are clearly specified.
Continue on blank sheets if necessary and attach to this report.

INSTRUCTIONS FOR SECTION 11 - CAUSAL FACTORS

a. Review thoroughly. Answer each question by marking the appropriate block. If any answer is yes, explain in item 13 below. Consider, as a minimum, the
following:

(1) DESIGN - Did inadequacies associated with the building or work site play a role? Would an improved design or layout of the equipment or facilities reduce the
likelihood of similar accidents? Were the tools or other equipment designed and intended for the task at hand?

(2) INSPECTION/MAINTENANCE - Did inadequately or improperly maintained equipment, tools, workplace, etc. create or worsen any hazards that contributed to
the accident? Would better equipment, facility, work site or work activity inspections have helped avoid the accident?

(3) PERSON'S PHYSICAL CONDITION - Do you feel that the accident would probably not have occurred if the employee was in "good" physical condition? If the
person involved in the accident had been in better physical condition, would the accident have been less severe or avoided altogether? Was over exertion a
factor?

(4) OPERATING PROCEDURES - Did a lack of or inadequacy within established operating procedures contribute to the accident? Did any aspect of the
procedures introduce any hazard to, or increase the risk associated with the work process? Would establishment or improvement of operating procedures
reduce the likelihood of similar accidents?

(5) JOB PRACTICES - Were any of the provisions of the Safety and Health Requirements Manual (EM 385-1-1) violated? Was the task being accomplished in a
manner which was not in compliance with an established job hazard analysis or activity hazard analysis? Did any established job practice (including EM
385-1-1) fail to adequately address the task or work process? Would better job practices improve the safety of the task?

(6) HUMAN FACTORS - Was the person under undue stress (either internal or external to the job)? Did the task tend toward overloading the capabilities of the
person; i.e., did the job require tracking and reacting to many external inputs such as displays, alarms, or signals? Did the arrangement of the workplace tend
to interfere with efficient task performance? Did the task require reach, strength, endurance, agility, etc., at or beyond the capabilities of the employee? Was
the work environment ill-adapted to the person? Did the person need more training, experience, or practice in doing the task? Was the person inadequately
rested to perform safely?

(7) ENVIRONMENTAL FACTORS - Did any factors such as moisture, humidity, rain, snow, sleet, hail, ice, fog, cold, heat, sun, temperature changes, wind, tides,
floods, currents, dust, mud, glare, pressure changes, lightning, etc., play a part in the accident?

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 11 of 13 Pages
(8) CHEMICAL AND PHYSICAL AGENT FACTORS - Did exposure to chemical agents (either single shift exposure or long-term exposure) such as dusts, fibers
(asbestos, etc.), silica, gases (carbon monoxide, chlorine, etc.,), mists, steam, vapors, fumes, smoke, other particulates, liquid or dry chemicals that are
corrosive, toxic, explosive or flammable, by products of combustion or physical agents such as noise, ionizing radiation, non-ionizing radiation (UV radiation
created during welding, etc.) contribute to the accident/incident?

(9) OFFICE FACTORS - Did the fact that the accident occurred in an office setting or to an office worker have a bearing on its cause? For example, office workers
tend to have less experience and training in performing tasks such as lifting office furniture. Did physical hazards within the office environment contribute to
the hazard?

(10) SUPPORT FACTORS - Was the person using an improper tool for the job? Was inadequate time available or utilized to safely accomplish the task? Were
less than adequate personnel resources (in terms of employee skills, number of workers, and adequate supervision) available to get the job done properly?
Was funding available, utilized, and adequate to provide proper tools, equipment, personnel, site preparation, etc.?

(11) PERSONAL PROTECTIVE EQUIPMENT - Did the person fail to use appropriate personal protective equipment (gloves, eye protection, hard-toed shoes,
respirator, etc.) for the task or environment? Did protective equipment provided or worn fail to provide adequate protection from the hazard(s)? Did lack of or
inadequate maintenance of protective gear contribute to the accident?

(12) DRUGS/ALCOHOL - Is there any reason to believe the person's mental or physical capabilities, judgment, etc., were impaired or altered by the use of drugs
or alcohol? Consider the effects of prescription medicine and over the counter medications as well as illicit drug use. Consider the effect of drug or alcohol
induced "hangovers".

b. WRITTEN JOB/ACTIVITY HAZARD ANALYSIS - Was a written Job/Activity Hazard Analysis completed for the task being performed at the time of the
accident? Mark the appropriate box. If one was performed, attach a copy of the analysis to the report.

INSTRUCTIONS FOR SECTION 12 - TRAINING

a. WAS PERSON TRAINED TO PERFORM ACTIVITY/TASK? - For the purpose of this section "trained" means the person has been provided the necessary
information (either formal and/or on-the-job (OJT) training) to competently perform the activity/task in a safe and healthful manner.

b. TYPE OF TRAINING - Mark the appropriate box that best indicates the type of training; (classroom or on-the-job) that the injured person received, before the
accident happened.

c. DATE OF MOST RECENT TRAINING - Enter YYYYMMDD of the last formal training completed that covered the activity task being performed at the time of the
accident.

INSTRUCTIONS FOR SECTION 13 - CAUSES

a. DIRECT CAUSES - The direct cause is that single factor, which most directly lead to the accident. See examples below.

b. INDIRECT CAUSES - Indirect causes are those factors which contributed to but did not directly initiate the occurrence of the accident.

Examples for section 13:

a. Employee was dismantling scaffold and fell 12 feet from unguarded opening.

Direct cause: failure to provide fall protection at elevation. Indirect causes: failure to enforce USACE safety requirements; improper training/motivation of
employee (possibility that employee was not knowledgeable of USACE fall protection requirements or was lax in his attitude towards safety); failure to ensure
provision of positive fall protection whenever elevated; failure to address fall protection during scaffold dismantling in phase hazard analysis.

b. Private citizen had stopped his vehicle at intersection for red light when vehicle was struck in rear by USACE vehicle. (Note: USACE vehicle was in proper/safe
working condition).

Direct cause: failure of USACE driver to maintain control of and stop USACE vehicle within safe distance.

Indirect cause: failure of employee to pay attention to driving (defensive driving).

INSTRUCTIONS FOR SECTION 14 - ACTION TO ELIMINATE CAUSE(s)

DESCRIPTION - Fully describe all the actions taken, anticipated, and recommended to eliminate the cause(s) and prevent reoccurrence of similar accidents/
illnesses. Continue on blank sheets of paper if necessary to fully explain and attach to the completed report form.

INSTRUCTIONS FOR SECTION 15 - DATES FOR ACTION

a. BEGIN DATE - Enter the date YYYYMMDD when the corrective action(s) identified in section 14 will begin.

b. COMPLETE DATE - Enter the date YYYYMMDD when the corrective action(s) identified in section 14 will be completed.

c. DATE SIGNED - Enter YYYYMMDD that the report was signed by the responsible supervisor.

d.e.. TITLE AND SIGNATURE - Enter the title and signature of supervisor completing the accident report. For a GOVERNMENT employee accident/illness the
immediate supervisor will complete and sign the report. For PUBLIC accidents the USACE Project Manager/Area Engineer responsible for the USACE
property where the accident happened shall complete and sign the report. For CONTRACTOR accidents the Contractor's project manager shall complete
and sign the report and provide to the USACE supervisor responsible for oversight of that contractor activity. This USACE supervisor shall also sign the
report. Upon entering the information required in 15c., 15d., 15e., 15f. and 15g. below, the responsible USACE supervisor shall forward the report for
management review as indicated in section 16.

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 12 of 13 Pages
f. ORGANIZATION NAME - For GOVERNMENT employee accidents enter the USACE organization name (Division, Branch, Section, etc.) of the injured
employee. For PUBLIC accidents enter the USACE organization name for the person identified in block 15d. For CONTRACTOR accidents enter the USACE
organization name for the USACE office responsible for providing contract administration oversight.

g. OFFICE SYMBOL - Enter the latest complete USACE Office Symbol for the USACE organization identified in block 15f.

INSTRUCTIONS FOR SECTION 16 - MANAGEMENT REVIEW (1st)

1ST REVIEW - Each USACE FOA shall determine who will provide 1st management review. The responsible USACE supervisor in section 15d. shall forward the
completed report to the USACE office designated as the 1st Reviewer by the FOA. Upon receipt, the Chief of the Office shall review the completed report, mark
the appropriate box, provide substantive comments, sign, date, and forward to the FOA Staff Chief (2nd review) for review and comment.

INSTRUCTIONS FOR SECTION 17 - MANAGEMENT REVIEW (2nd)

2ND REVIEW - The FOA Staff Chief (i .e., FOA Chief of Construction, Operations, Engineering, Planning, etc.) shall mark the appropriate box, review the
completed report, provide substantive comments, sign, date, and return to the FOA Safety and Occupational Health Office.

INSTRUCTIONS FOR SECTION 18 - SAFETY AND OCCUPATIONAL HEALTH REVIEW

3RD REVIEW - The FOA Safety and Occupational Health Office shall review the completed report, mark the appropriate box, ensure that any inadequacies,
discrepancies, etc. are rectified by the responsible supervisor and management reviewers, provide substantive comments, sign, date and forward to the FOA
Commander for review, comment, and signature.

INSTRUCTION FOR SECTION 19 - COMMAND APPROVAL

4TH REVIEW - The FOA Commander shall (to include the person designated Acting Commander in his absence) review the completed report, comment if
required, sign, date, and forward the report to the FOA Safety and Occupational Health Office. Signature authority shall not be delegated.

ENG FORM 3394INST, MAR 1999 PREVIOUS EDITIONS ARE OBSOLETE. Page 13 of 13 Pages