AG 22-074 - DOCRETURN TO: EXT:
AUTUMN GRESSETT 6914
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
ORIGINATING DEPT./DIV: PRCS/PAEC
ORIGINATING STAFF PERSON: AUTUMN GRESSETr
EXT: 6914 _ 3. DATE REQ. BY:
4. TYPE OF DOCUMENT (CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ)
❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT
❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG
❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G BOND RELATED DOCUMENTS)
❑ ORDINANCE ❑ RESOLUTION
0 CONTRACT AMENDMENT (AG#): 22-074 ❑ INTERLOCAL
❑O OTHER WA DEPARTMENT OF CORRECTIONS MASTER AGREEMENT- CLASS V COMMUNITY RESTITUTION PROGRAMS AMENDMENT
PROJECT NAME: CLASS V COMMUNITY RESTITUTION PROGRAMS
NAME OF CONTRACTOR: STATE OF WASHINGTON, DEPARTMENT OF CORRECTIONS, WESTERN WASHINGTON WORKCREW
ADDRES S: ' 851 POPLAR PLACE SOUTH - MS: TB-76, SEATTLE, WA 98144
E-MAIL: RJVERTZ@DOCI.WA.GOV
SIGNATURE NAME:
TELEPHONE
_— FAX: 206-720-342e
TITLE
206-726-6719
7. EXHIBITS AND ATTACHMENTS: R SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL
OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS
8. TERM: COMMENCEMENT DATE: J i42 Q 21 COMPLETION DATE: SEPTEMBER 30, 2026
TOTAL COMPENSATION $ up to $75.000 per year (INCLUDE EXPENSES AND SALES TAX, IF ANY)
(IF CALCULATED ON HOURLY LABOR CHARGE -ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED
❑ YES ❑ NO IF YES, $ PAID BY: ❑ CONTRACTOR ❑ CITY
RETAINAGE: RETAINAGE AMOUNT:
❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAWAGE BOND PROVIDE;
R PURCHASING: PLEASE CHARGE TO: PARKS •100-331-576-82-492 PUBLIC WORKS (STREETS): 106-3200-250-537-10480
10. DOCUMENT/CONTRACT REVIEW INITIAL / DATE REVIEWED INITIAL / DATE APPROVED
� PROJECT MANAGER AG 10/30/2023
❑ DIRECTOR
❑ RISK MANAGEMENT (IF APPLICABLE)
O LAW
11. COUNCIL APPROVAL (IF APPLICABLE)
12. CONTRACT SIGNATURE ROUTING
❑ SENT TO VENDOR/CONTRACTOR
JE 11/15/23
SCHEDULED COMMITTEE DATE:
SCHEDULED COUNCIL DATE:
DATE SENT:
COMMITTEE APPROVAL DATE:
COUNCIL APPROVAL DATE:
DATE REC'D:
❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
❑ CREATE ELECTRONIC REMINDER/NOTIFICATION FOR 1 MONTH PRIOR TO EXPIRATION DATE
(Include dept. support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.)
INITIAL / DATE SIGNED
VK-LAW DEPARTMENT l
1�160NATORY (MAYOR OR DIRECTOR)
❑ CITY CLERK l
❑ ASSIGNED AG# AG# -Q
❑ SIGNED COPY RETURNED DATE SENT: ��. Co . 94
COMMENTS:
Please see notes in Attachments in addition to suggested changes to amendment, agenda bill, and staff report. JE 11/15/23
DocuSign Envelope ID: B72FC3E0-B3F3-4083-8642-917045006F5D
Washington State Contract No. K12614
Department of Corrections Amendment No.1
Thie Amendment is made between the Washington State Department of Corrections,
hereinafter referred to as "Department," and City of Federal Way, hereinafter referred to as "Recipient,"
for the purpose of amending the above -referenced Contract, heretofore entered into between the
Department and Recipient.
WHEREAS the purpose of this Amendment is to extend the contract term.
NOW THEREFORE, in consideration of the terms and conditions contained herein, or attached
and incorporated and made a part hereof, the Department and Recipient agree as follows:
SECTION 3. TERM is amended as follows:
The term of this Master Contract Agreement shall begin July 01, 2021 and continue through (G m;'^2923))
September 30, 2026 unless terminated sooner as provided for herein.
Additions to this text are shown by underline and deletions by ((str-ikeeui)). All other terms and conditions
remain in full force and.effect. The effective date of this Amendment is December 01, 2023.
THIS AMENDMENT, consisting of two (2) pages is executed by the persons signing below who warrant
that they have the authority to execute this Amendment.
CITY OF FEDERAL WAY
t latore)
im Ferrell
(Printed Name)
Mayor
(Title)
(Date)
DEPARTMENT OF CORRECTIONS
❑ocuSrgnned by:
7�
vnr� gV43iA5er
{Signature}
Darvl Huntsinaer
(Printed Name)
Contracts Administrator
(Title)
1/29/2024
(Date)
Washington State K12614(1) Page 1 of 2
Department of Corrections 23RCP
(SiOurej r
Stephanie Courtney �f
(Printed Name)
City Clerk
(Title)
(Date)
0���-eb,A (W ,
(5i ature)
J. Ryan Call
(Printed Name)
City Attorney
(Title)
(Date)
Approved as to Form: This Amendment format was approved by the office of the Attorney General.
Approval on file.
Washington State K12614(1) Page 2 of 2
Department of Corrections 23RCP
WASHINGTON STATE DEPARTMENT OF CORRECTIONS
Community Corrections Division
CLASS V Work Project Description
Contract Number: K12614
Recipient: City of Federal Way
Recipient is: ® Government Entity ❑ State Agency ❑ Public Benefit Nonprofit & Evidence
Attached ❑
Recipient Contact: Tason Gerwen Phone: 253-835-8962 Email: Jason.gerwen@cityoffederalway.com
Department Contact: Rene Vertz Phone: 206-786-3273 Email: rivertz@docl.wa.gov
Work Project Title: City of Federal Wave Parks & Recreation Qgzarhnent
Project Level: ® 1 ® 2 ® 3
Workers will: Provide litter pick-ups, illegal dumping site clean-ups, and general labor on property
owned by the City of Federal Way as outlined in the Statement of Work attached (Attachment E).
Workers will not perform any work listed in the Prohibited Work document (Attachment C).
Number of Workers on crew: Minimum of 2 for illegal dumping site clean-ups and any Level 3 work.
One -worker crews are permissible for litter pick-ups on city streets and general labor in parks and at
Town Square.
Project Location: Various worksites in the City of Federal Way
Project Period (One year maximum): December 1, 2023 through September 30, 2024
1. Projected Total Number of Crew Hours, Number of Workers: N/A
2. Minimums for Set Monthly Rate and/or Full or Half Day Rate: N/A
3. Approximate Work Hours: Arrive at 8:30 a.m. Depart at 2:30 p.m.
Special Payment Terms. Recipient will pay DOC:
1. Service Maximum: City of Federal Way will pay DOC a maximum of $75,000 for services provided
per year.
2. Invoice: DOC will invoice City of Federal Way for offender worker services at the rate of 25 da
per person (workers + supervisors). Each dated and itemized invoice to City of Federal Way will
include: Agreement AK12614, dates and hours of services provided, description of the work, and
the amount of payment due.
3. Administrative and program overhead at 10% of the actual monthly billing which will cover the
cost of miscellaneous expenditures needed for the specified contract work with the City of
Federal Way. Expenditures include, but are not limited to, office supplies, hand tools, shovels,
rakes, litter pickers, garbage bags, sharps containers, gloves and boots.
4. Vehicle operation costs for assigned time on City of Federal Way's contracts work;
reimbursement at the current privately owned vehicle mileage rate (as determined by OFM). The
current rate can be located at htti2s:Hofm.wa.gov/.accounting/administrative-accounting-
resources/travel.
5. L&I Premiums: Reimbursement for worker L&I premiums at the current DOC L&I rate. The rate
for 2023 is S0.3753 per worker per hour. (This rate potentially changes every year on January 15t,
so Work Project Descriptions that overlap years may have changes to this rate on our invoices
State of Washington Attachment A
Department of Corrections K12614
starting January Pt. We will make a note of any changes to the rate in your January billing
statement).
PPE, Tools and Equipment Provided by:
Recipient: Will provide any specialty equipment needed to complete specific projects. Will pay for waste
disposal either through providing waste receptacles at the work sites, or at City landfill or transfer
station; dump cards or account information for waste disposal will be provided to DOC Workcrew for
use on City of Federal Way projects if necessary.
Specialty PPE, Tools and Equipment Training Provided by Recipient?
DOC: Will provide Personal Protective Equipment (PPE) and tools and supplies for general litter pick-
up, removal of illegally dumped materials and brush removal, including but not limited to: gloves,
boots rain gear, hard hats, hearing and eye protection, shovels, rakes, trash bags, pickers, surgical
masks, disposable gloves, hand sanitizer, etc.
JSA Worksheet completed and attached?
Recipient will provide the DOC contract manager with a signed Job Safety Analysis form for each type of
service prior to any work taking place (Attachment D). The Job Safety Analysis form remains valid for
the length of the project period. The types of services provided by offender workers include 1) Illegal
dump site clean-up, 2) Litter Pick-ups, 3) General Labor.
Additional Terms:
DOC will send a monthly activity report, photo documentation (before and after) of services performed,
and dumpsite invoices (if required) along with the billing statement as requested by the recipient.
CITY OF E L WAY
gnatu re
Printed Name & Title
i �v
Date
DEPARTMENT OF CORRECTIONS
Signature of Field Administrator or Work
Release and Residential Program Coordinator
Section 5/CCD
Section/Facility
Date
Please email a copy of this Work Project Description to docclacontracts@DOCI. WA. GOV
within two (2) calendar days after it is signed by the second of both Parties. THANK -YOU
State of Washington Attachment A
Department of Corrections K12614
starting January Id. We will make a note of any changes to the rate in your January billing
statement).
PPE, Tools and Equipment Provided by:
Recipient: Will provide any specialty equipment needed to complete specific projects. Will pay for waste
disposal either through providing waste receptacles at the work sites, or at City landfill or transfer
station; dump cards or account information for waste disposal will be provided to DOC Workcrew for
use on City of Federal Way projects if necessary.
Specialty PPE, Tools and Equipment Training Provided by Recipient?
DOC: Will provide Personal Protective Equipment (PPE) and tools and supplies for general litter pick-
up, removal of illegally dumped materials and brush removal, including but not limited to: gloves,
boots rain gear, hard hats, hearing and eye protection, shovels, rakes, trash bags, pickers, surgical
masks, disposable gloves, hand sanitizer, etc.
JSA Worksheet completed and attached?
Recipient will provide the DOC contract manager with a signed Job Safety Analysis form for each type of
service prior to any work taking place (Attachment D). The Job Safety Analysis form remains valid for
the length of the project period. The types of services provided by offender workers include 1) Illegal
dump site clean-up, 2) Litter Pick-ups, 3) General Labor.
Additional Terms:
DOC will send a monthly activity report, photo documentation (before and after) of services performed,
and dumpsite invoices (if required) along With the billing statement as requested by the recipient.
CITY OF E RA L WAY
i�nalur'e
Printed Name L Title
bate i I L,�Ea
DEPARTMENT OF CORRECTIONS
:S A2_
Signature of Field Administrator or Work
Release and Residential Program Coordinator
Section 5/CCD
Section/Facility
� /1f.f�r
Date
Please email a copy of this Work Project Description to docclaconlraclsQDOCi.WA.GQV
within two (2) calendar days after it is signed by the second of both Parties. THANK -YOU
State of Washington Attachment A
Department of Corrections K12614
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level: 1, 2 and 3
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason.gerwen@cityoffederalway.com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: r vertz dacl.wa. ov
DOC Matrix — Work Project Title: General Labor Project Date(s): 12/01/2023-9/30/2024
Project Location(s): Various locations within the City of Federal Way Contract: K12614
ELEMENTS/ACTIVITIES
SPECIFIC
HAZARDS CONTROLS PPE
PROVIDER of
TASKS
PPE & TRAIN
TO USE
Weed and Brush Removal
Cutting and
Cuts from tools/small Use proper techniques for
Gloves, hard
DOC
removing brush,
machinery handling tools, be aware of
hats, boots,
grass and weeds
I surroundings, do not touch sharp
equipment -
blades, closed -toed shoes, long
specific safety
pants and long-sleeved shirts
training
Scrapes/Cuts from
Be aware of surroundings, wear
Boots, gloves,
DOC
brush and branches
long pants and long-sleeved shirts
hard hats
Landscaping Weed eating Cuts from tools/small
Use proper techniques for
Gloves, hard
DOC
machinery
handling tools, be aware of
hats, boots,
surroundings, do not touch sharp
equipment -
blades, closed -toed shoes, long
specific safety
pants and long-sleeved shirts
training
Learn and use proper lifting
Gloves, boots
DOC
Lifting and moving Lifting injury
plants, soil and
techniques, obtain assistance
landscaping rock
from other crew members for
heavy or large items
Landscaping continued
Planting trees,
Cuts from tools/small
Use proper techniques for
Gloves, hard
DOC
shrubs and other
machinery
handling tools, be aware of
hats, boots,
plants
surroundings, do not touch sharp
equipment -
blades, closed -toed shoes, long
specific safety
pants and long-sleeved shirts
training
Trail Construction
Cutting and
Cuts from tools/small
Use proper techniques for
Gloves, hard
DOC
removing brush
machinery
handling tools, be aware of
hats, boots,
Washington State K12614 Page 1 of 4
Department of Corrections Attachment D
surroundings, do not touch sharp
equipment -
blades, closed -toed shoes, long
specific safety
pants and long-sleeved shirts,
training
Wood Chipping Disposal of
Cuts/injuries from
Use proper techniques for
Gloves, hard
branches and
machinery
handling tools, be aware of
hats, boots,
other wood
surroundings, do not touch sharp
equipment -
products with a
blades, closed -toed shoes, long
specific safety
chipping machine
pants and long-sleeved shirts,
training
Carpentry/Construction
Putting together
Lifting injury
Learn and use proper lifting
Gloves, boots
and repairing
techniques, obtain assistance
small structures
from other crew members for
and furniture
heavy or large items
Cuts/injuries from saws
Use proper techniques for
Gloves, hard
and other machinery
handling tools, be aware of
hats, boots,
surroundings, do not touch sharp
equipment -
blades, closed -toed shoes, long
specific safety
pants and long-sleeved shirts,
training
Be aware of surroundings, have
Dust mask, eye
Dust/Debris Exposure
windows open and allow air -flow
protection
to eyes and mouth
to reduce dust accumulation in
_
f Weather— rain/snow
the air, work slowly and carefully
All activities
Wear appropriate clothing and
Rain Coat,
footwear to keep warm and dry
boots, hard
i
hats, gloves
Weather - heat
Wear appropriate clothing, drink
Hard hats
plenty of fluids, take breaks in the
shade if possible
Exposure to
Wear appropriate clothing,
Gloves, surgical
communicable
maintain distance from others
masks or other
diseases/pathogens
when possible, do not touch
face coverings,
items or people without proper
boots
PPE, do not work while sick
Be aware of what you are
Puncture
Hand Puncture
touching, do not reach into areas
resistant gloves,
you cannot see
litter pickers
Be aware of surroundings, have Dust mask, eye
Dust Exposure
windows open and allow air -flow protection
to reduce dust accumulation in
the air
DOC
DOC
DOC
DOC
DOC
DOC
DOC
DOC
DOC
Washington State K12614 Page 2 of 4
Department of Corrections Attachment D
Debris in Eyes Be aware of surroundings, work Eye protection
slowly l
Slipping/tripping/falling Watch where you are walking, Hard -soled
step carefully on or around items boots or rubber
Traffic noise
Bug bites
Lifting items into trucks/vans Placing items into Lifting injury
trucks or vans for
disposal
Crew Deployment Entering and Struck by moving
Exiting Vehicles vehicle
boots suitable
for outdoor
work.
Ear plugs
Wear long pants and long sleeved
Bug repellant
shirts
Learn and use proper lifting
techniques, obtain assistance
from other crew members for
heavy or large items
_
Exit vehicle on the side of the
Wear high
vehicle away from the road
visibility ANSI
Class 2 or 3
safety vests and
hard hats
Work facing oncoming traffic
Never enter traffic to retrieve
equipment
Park vehicle as far off the
J roadway as is safe
Wear high visibility clothing, use
traffic cones and emergency
flashers on vehicles
Travel in vehicles Riding to and from Vehicle accident Wear seatbelts and remain
worksite locations seated in moving vehicles at all
times, do not lean out or stick
hands out of open windows
SPECIAL EQUIPMENT THAT WORKERS WILL USE FOR THIS PROJECT:
TASK I HAZARDS TYPE I RISK LEVEL I EQUIPMENT
Weed eating Cuts from tools/small
machinery _
Cutting and removing brush Cuts from tools/small
machinery
Washington State
Department of Corrections
Moderate I Gas or electric weed eaters
Moderate I Clippers, pruners
K12614
Attachment D
Seatbelts
DOC
DOC
DOC
DOC
DOC
DOC
DOC
DOC
DOC
DOC
9C0
PROVIDER of SPECIAL EQUIP.
& TRAIN TO USE
DOC
IOO
Page 3 of 4
Disposal of branches and
Cuts/injuries from
Moderate
Wood chipper
City of Federal Way
other wood products with a
machinery
chipping machine
Cutting brush/blackberries
Scrapes/cuts from thorns
Low
Clippers, Pruners
DOC
DOC
Planting trees/bushes
Scrapes from branches
I Low
Shovels, Rakes
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
Department JSA Contact
9/14/2023
(Signature) Date
>24U* i4,Rene Vertz — Wdrkcrew Program Manager
(Printed Name) Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: "operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this point, assume
that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result from each hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity, emissions, chemicals, low
oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing in the ears
and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation, unconsciousness and even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local exhaust
ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or minimized with controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State
Department of Corrections
K12614
Attachment D
Page 4 of 4
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level: 2
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason, gerwen acityoffederaWay. com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: rive rtzCa).doc1.wa.gov
DOC Matrix — Work Project Title: Illegal Dumpsite Cleanup Project Date(s): 12/01/2023-9/3012024
Project Location(s): Various locations within the City of Federal Way Contract: K12614
ELEMENTS/ACTIVITIES
Illegal dumpsite cleanups
SPECIFIC
TASKS
Picking up litter,
furniture and other
items illegally
dumped in areas
around the City
HAZARDS
CONTROLS
PPE
PROVIDER of
PPE & TRAIN TO
Wear appropriate clothing
Rain Coat, boots,
USE
Weather— rain/snow
DOC
and footwear to keep warm
hard hats, gloves
and dry
Hard hats
Weather - heat
Wear appropriate clothing,
DOC
drink plenty of fluids, take
breaks in the shade if possible
Exposure to Wear appropriate clothing, Gloves, surgical
DOC
communicable maintain distance from others masks or other
diseases/pathogens when possible, do not touch face coverings,
items or people without boots
proper PPE, do not work while
sick
Be aware of what you are
Puncture
DOC
Hand Puncture
touching, do not reach into
resistant gloves,
areas you cannot see
litter pickers
Dust mask, eye
Be aware of surroundings,
DOC
Dust Exposure
have windows open and allow
protection
air -flow to reduce dust
accumulation in the air
Debris in Eyes
Be aware of surroundings, 1
Eye protection
DOC
work slowly
Washington State K12614 Page 1 of 3
Department of Corrections Attachment D
Slipping/tripping/falling
Watch where you are walking,
Hard -soled boots
DOC
step carefully on or around
or rubber boots
items
suitable for
outdoor work.
Traffic noise
Ear plugs
DOC
Bug bites
Wear long pants and long
Bug repellant
DOC
Lifting injury
sleeved shirts
Lifting items into trucks/vans
Placing items into
Learn and use proper lifting
DOC
trucks or vans for
techniques, obtain assistance
disposal
from other crew members for
heavy or large items
Crew Deployment
Entering and Exiting
Struck by moving
Exit vehicle on the side of the
Wear high
DOC
Vehicles
vehicle
vehicle away from the road
visibility ANSI
Class 2 or 3
safety vests and
hard hats
Work facing oncoming traffic
Never enter traffic to retrieve
DOC
DOC
equipment
Park vehicle as far off the
DOC
roadway as is safe
Wear high visibility clothing,
DOC
use traffic cones and
emergency flashers on
vehicles
Travel in vehicles
Riding to and from
Vehicle accident
Wear seatbelts and remain
Seatbelts
DOC
worksite locations
seated in moving vehicles at
all times, do not lean out or
stick hands out of open
windows
SPECIAL EQUIPMENT THAT
WORKERS WILL
USE FOR THIS PROJECT:
TASK
HAZARDS TYPE
RISK LEVEL
EQUIPMENT
PROVIDER of SPECIAL EQUIP.
& TRAIN TO USE
Picking up piles of garbage
Scrapes/cuts from hidden
Mod
Shovels, Rakes
DOC
sharp objects
Scrapes/cuts from sharp
Mod
Litter Pickers
Picking up small items
DOC
objects
Cutting brush/blackberries
Scrapes/cuts from thorns
Mod
I Clippers, Pruners I
DOC
Washington State K12614 Page 2 of 3
Department of Corrections Attachment D
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
Department JSA Contact
9/14/2023
(Signature) Date
Rene Vertz — Workcrew Program Manager
J-91y�� (Printed Name)
Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: 'operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this
point, assume that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result
from each hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity,
emissions, chemicals, low oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing
in the ears and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation,
unconsciousness and even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local
exhaust ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or
minimized with controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 3 of 3
Department of Corrections Attachment D
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level. 2
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason. erwen cit offederaiwa .cam
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: rivertz@docl.wa.gov
DOC Matrix — Work Project Title: Litter Cleanup Project Date(s): 12/01/2023-9/30/2024
Project Location(s): Various locations within the Ci of Federal Wa Contract: K12614
ELEMENTS/ACTIVITIES
Litter removal
SPECIFIC
TASKS
Picking up litter on
the side of the
road
HAZARDS
Weather — rain/snow
Weather - heat
Exposure to
communicable
diseases/pathogens
Hand Puncture
Dust Exposure
Debris in Eyes
CONTROLS PPE
Wear appropriate clothing
and footwear to keep warm
and dry
Wear appropriate clothing,
drink plenty of fluids, take
breaks in the shade if
possible
Wear appropriate clothing,
maintain distance from
others when possible, do not
touch items or people
without proper PPE, do not
work while sick
Be aware of what you are
touching, do not reach into
areas you cannot see
Be aware of surroundings,
have windows open and
allow air -flow to reduce dust
accumulation in the air
Be aware of surroundings,
work slowly
Washington State K12614
Department of Corrections Attachment D
Rain Coat, boots,
hard hats, gloves
Hard hats
PROVIDER of
PPE & TRAIN TO
USE
DOC
DOC
Gloves, surgical DOC
masks or other
face coverings,
boots
Puncture
resistant gloves,
litter pickers
Dust mask, eye
protection
DOC
DOC
Eye protection DOC
Page 1 of 3
Slipping/tripping/falling
Watch where you are Hard -soled boots
DOC
walking, step carefully on or or rubber boots
around items suitable for
outdoor work.
Traffic noise
Ear plugs
DOC
Bug bites
Wear long pants and long
Bug repellant
DOC
sleeved shirts
Placing items into
Lifting items into trucks/vans
Lifting injury
Learn and use proper lifting
DOC
trucks or vans for
techniques, obtain assistance
disposal
from other crew members for
heavy or large items
Crew Deployment
Entering and Exiting
Struck by moving
Exit vehicle on the side of the Wear high
DOC
Vehicles
vehicle
vehicle away from the road visibility ANSI
Class 2 or 3
safety vests and
hard hats
Work facing oncoming traffic I
Never enter traffic to retrieve
DOC
DOC
equipment I
Park vehicle as far off the
DOC
roadway as is safe
DOC
_
Wear high visibility clothing,
use traffic cones and
emergency flashers on
vehicles
Travel in vehicles Riding to and from Vehicle accident Wear seatbelts and remain Seatbelts DOC
worksite locations seated in moving vehicles at
all times, do not lean out or
stick hands out of open
windows
SPECIAL EQUIPMENT THAT
WORKERS WILL USE
FOR THIS PROJECT:
TASK
HAZARDS TYPE
RISK LEVEL
EQUIPMENT
PROVIDER of SPECIAL EQUIP.
& TRAIN TO USE
Scrapes/cuts from hidden
Mod
DOC
Picking up piles of garbage
Shovels, Rakes
sharp objects
Picking up small items
Scrapes/cuts from sharp
Mod
Litter Pickers
DOC
objects
Washington State K12614 Page 2 of 3
Department of Corrections Attachment D
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
�_.__I LMM
Department JSA Contact
9/14/2023
(Signature) Date
Rene Vertz — Workcrew Program Manager
(Printed Name) Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: 'operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this point,
assume that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result from each
hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity, emissions,
chemicals, low oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing in the
ears and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation, unconsciousness and
even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local
exhaust ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or minimized with
controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 3 of 3
Department of Corrections Attachment D
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: Cily of Federal Way Parks Department DOC Matrix - Project Risk Level: 2
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason.gerwen@citVoffederalway.com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: rivertz(J5Wc1.wa.gov
DOC Matrix — Work Project Title: Town Center Litter Cleanup and Landscaping Maintenance
Project Date(s): 12/01/2023-9/30/2024
Project Location(s): Federal Way Town Center Performing Arts & Events Center Contract: K12614
ELEMENTS/ACTIVITIES f SPECIFIC TASKS
Weed and Brush Removal
Landscaping
Cutting and removing
brush, grass and
weeds
Lifting and moving
plants, soil and
landscaping rock
HAZARDS
CONTROLS
PPE
PROVIDER of PPE
I
Gloves, hard hats,
& TRAIN TO USE
DOC
Cuts from tools/small
Use proper techniques
machinery
for handling tools, be
boots, equipment -
aware of
specific safety
surroundings, do not
training
touch sharp blades,
closed -toed shoes,
long pants and long-
sleeved shirts
DOC
Scrapes/Cuts from Be aware of
_
Boots, gloves, hard
brush and branches surroundings, wear
hats
long pants and long-
sleeved shirts
Gloves, boots
Lifting injury
Learn and use proper
DOC
lifting techniques,
obtain assistance from
other crew members
for heavy or large
items
Planting trees, shrubs Cuts from tools/small Use proper techniques I Gloves, hard hats,
and other plants machinery for handling tools, be boots, equipment -
aware of specific safety
surroundings, do not training
touch sharp blades,
DOC
Washington State K12614 Page 1 of 4
Department of Corrections Attachment D
closed -toed shoes,
long pants and long-
sleeved shirts
Litter removal
Picking up litter in the
Fall down stairs
Be aware of
DOC
parking lots and on
surroundings and
the outdoor steps of
where you step. Step
the Town Center
carefully and hold
property
handrails when
walking up or down
stairs
All Activities
Weather— rain/snow
Wear appropriate
Rain Coat, boots,
DOC
clothing and footwear
hard hats, gloves
_
to keep warm and dry
Wear appropriate
Weather - heat
Hard hats
DOC
clothing, drink plenty
of fluids, take breaks
in the shade if possible
Exposure to
Wear appropriate
Gloves, surgical
DOC
communicable
clothing, maintain
masks or other
diseases/pathogens
distance from others
face coverings,
when possible, do not
boots
touch items or people
without proper PPE,
do not work while sick
Be aware of what you
Puncture resistant
DOC
Hand Puncture
are touching, do not
gloves, litter
reach into areas you
pickers
cannot see
Be aware of
Dust mask, eye
DOC
surroundings, have
protection
windows open and
Dust Exposure
allow air -flow to
reduce dust
accumulation in the air
Be aware of Eye protection
DOC
Debris in Eyes
surroundings, work
slowly i
Slipping/tripping/falling
Watch where you are Hard -soled boots
DOC
walking, step carefully or rubber boots
on or around items
Washington State K12614 Page 2 of 4
Department of Corrections Attachment D
suitable for
outdoor work.
L
Traffic noise
Ear plugs
DOC
Bug bites Wear long pants and
Bug repellant
DOC
long sleeved shirts
Lifting items into trucks/vans
Placing items into
Lifting injury Learn and use proper
DOC
trucks or vans for
lifting techniques,
disposal
obtain assistance from
other crew members
for heavy or large
items
Crew Deployment
Entering and Exiting
Struck by moving
Exit vehicle on the side
Wear high visibility
DOC
Vehicles
vehicle
of the vehicle away
ANSI Class 2 or 3
from the road
safety vests and
hard hats
Work facing oncoming
DOC
traffic
Never enter traffic to
DOC
retrieve equipment
Park vehicle as far off
DOC
the roadway as is safe
Wear high visibility
DOC
clothing, use traffic
cones and emergency
flashers on vehicles
Travel in vehicles
Riding to and from
Vehicle accident
Wear seatbelts and
Seatbelts
DOC
worksite locations
remain seated in
moving vehicles at all
times, do not lean out
or stick hands out of
open windows
SPECIAL EQUIPMENT THAT
WORKERS WILL USE
FOR THIS PROJECT:
TASK
HAZARDS TYPE
RISK LEVEL
- EQUIPMENT
PROVIDER of SPECIAL EQUIP.
& TRAIN TO USE
Picking up small items
Scrapes/cuts from sharp
Mod
Litter Pickers
DOC
objects
Planting trees/bushes
Scrapes from branches
Low
Shovels, Rakes
DOC
Leaf cleanup
Slipping on wet leaves
Low
Leaf blower
DOC
Washington State K12614 Page 3 of 4
Department of Corrections Attachment D
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
Department JSA Contact
I✓ f
9/14/2023
(Signature) Date
Rene Vertz — Workcrew Program Manager
,PI"-C4Of— (rnncea Name
Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: "operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this
point, assume that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result
from each hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity,
emissions, chemicals, low oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing
in the ears and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation,
unconsciousness and even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local
exhaust ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or
minimized with controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 4 of 4
Department of Corrections Attachment D
RETURN TO:
AUTUMN GRF,!S SETT
EXT:
6914
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
ORIGINATING DEPT./DIV. PRCS/PAEC
2. ORIGINATING STAFF PERSON: AUTUMN GRESSETT
EXT: 6914
3. DATE REQ. BY: ASAP
4. TYPE OF DOCUMENT (CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT (E.G, RFB, RFP, RFQ)
❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT
❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG
❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
❑ ORDINANCE ❑ RESOLUTION
❑ CONTRACT AMENDMENT(AG#): ❑ INTERLOCAL
❑O OTHER WA DEPARTMENT OF CORRECTIONS MASTER AGREEMENT - CLASS V COMMUNITY RESTITUTION PROGRAMS
S. PROJECT NAME: CLASS V COMMUNITY RESTITUTION PROGRAMS
C. NAME OF CONTRACTOR: STATE OF WASHINGTON, DEPARTMENT OF CORRECTIONS, WESTERN WASHINGTON WORKCREW
ADDRESS: 851 POPLAR PLACE SOUTH - MS: TB-76, SEATTLE, WA 98144
E-MAIL: RJVERTZ@DOCI.WA.GOV
SIGNATURE NAME:
_TELEPHONE
_ FAX:206-720-342P
TITLE
206-726-6719
7. EXHIBITS AND ATTACHMENTS: R SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL
OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS
8. TERM: COMMENCEMENT DATE: 10-1-Qcoa COMPLETION DATE: November 30, 2023
TOTAL COMPENSATION $ up to $75,000 per year (INCLUDE EXPENSES AND SALES TAX, IF ANY)
(IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED
❑ YES ❑ NO IF YES, $
RETAINAGE: RETAINAGE AMOUNT:
❑ PURCHASING: PLEASE CHARGE TO:
10. DOCUMENT/CONTRACT REVIEW
0 PROJECT MANAGER
❑ DIRECTOR
❑ RISK MANAGEMENT (IF APPLICABLE)
O LAW
11. COUNCIL APPROVAL (IF APPLICABLE)
12. CONTRACT SIGNATURE ROUTING
PAID BY: ❑ CONTRACTOR ❑ CITY
❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDEE
Vhk'i u
1 DATE REVIEWED INITIAL / DATE APPROVED
AG 11/12/2022
SCHEDULED COMMITTEE DATE: COMMITTEE APPROVAL DATE:
SCHEDULED COUNCIL DATE: COUNCIL APPROVAL DATE:
❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D:_
❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
❑ CREATE ELECTRONIC REMINDER/NOTIFICATION FOR 1 MONTH PRIOR TO EXPIRATION DATE
(Include dept. support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.)
INITIAL/ DATE SIGNED
�aAW DEPARTMENT +f 244-
+SIGNATORY (MAYOR OR IRECTOR) b v
❑ CITY CLERK I C
❑ ASSIGNED AG# OG
❑ SIGNED COPY RETURNED E SENT: • 1. a
COMMENTS: �� CLC�' "I ^� � 9-1'e) r 0—+L4
c'"
Pt ►l) Irs
1 nn74
WASHINGTON STATE DEPARTMENT OF CORRECTIONS
Community Corrections Division
CLASS V Work Project Description
Contract Number: K12614
Recipient: Ciiy of Federal Way
Recipient is: ® Government Entity ❑ State Agency ❑ Public Benefit Nonprofit & Evidence
Attached ❑
Recipient Contact: ason Gerwen Phone: 253-835-8962 Email: Jason.gerwenCncityoffederalway.com
Department Contact: Rene Vertz Phone: 206-786-3273 Email: rivertz@docl.wa.gov
Work Project Title: City of Federal Way Parks & Recreatim Qgyrtment
Project Level: ® 1 ® 2 ® 3
Workers will: Provide litter pick-ups, illegal dumping site clean-ups, and general labor on property
owned by the City of Federal Way as outlined in the Statement of Work attached (Attachment E).
Workers will not perform any work listed in the Prohibited Work document (Attachment C).
Number of Workers on crew: Minimum of 2 for illegal dumping site clean-ups and any Level 3 work.
One -worker crews are permissible for litter pick-ups on city streets and general labor in parks and at
Town Square.
Project Location: Various worksites in the City of Federal Way
Project Period (One year maximum): December 1, 2022 through November 30, 2023
1. Projected Total Number of Crew Hours, Number of Workers: N/A
2. Minimums for Set Monthly Rate and/or Full or Half Day Rate: N/A
3. Approximate Work Hours: Arrive at 8:30 a.m. Depart at 2:30 p.m.
Special Payment Terms. Recipient will pay DOC:
1. Service Maximum: City of Federal Way will pay DOC a maximum of $75,000 for services provided
per year.
2. Invoice: DOC will invoice city of Federal Way for offender worker services at the rate of 25 da
per n�P (workers + supervisors). Each dated and itemized invoice to City of Federal Way will
include: Agreement 9K12614, dates and hours of services provided, description of the work, and
the amount of payment due.
3. Administrative and program overhead at 10% of the actual monthly billing which will cover the
cost of miscellaneous expenditures needed for the specified contract work with the City of
Federal Way. Expenditures include, but are not limited to, office supplies, hand tools, shovels,
rakes, litter pickers, garbage bags, sharps containers, gloves and boots.
4. Vehicle operation costs for assigned time on City of Federal Way's contracts work;
reimbursement at the current privately owned vehicle mileage rate (as determined by OFM). The
current rate can be located at htWs.-//ofm.wa.gov/`accountingLadministrative-accoun tft-
resou rcesltrayel .
5. L&I Premiums: Reimbursement for worker L&I premiums at the current DOC L&I rate. The rate
for 2022 is $0.3659 per worker per hour. (This rate potentially changes every year on January 15t,
so Work Project Descriptions that overlap years may have changes to this rate on our invoices
State of Washington Attachment A
Department of Corrections K12614
starting January 1st. We will make a note of any changes to the rate in your January billing
statement).
PPE, Tools and Equipment Provided by:
Recipient: Will provide any specialty equipment needed to complete specific projects. Will pay for waste
disposal either through providing waste receptacles at the work sites, or at City landfill or transfer
station; dump cards or account information for waste disposal will be provided to DOC Workcrew for
use on City of Federal Way projects if necessary.
Specialty PPE, Tools and Equipment Training Provided by Recipient?
DOC: Will provide Personal Protective Equipment (PPE) and tools and supplies for general litter pick-
up, removal of illegally dumped materials and brush removal, including but not limited to: gloves,
boots rain gear, hard hats, hearing and eye protection, shovels, rakes, trash bags, pickers, surgical
masks, disposable gloves, hand sanitizer, etc.
JSA Worksheet completed and attached?
Recipient will provide the DOC contract manager with a signed Job Safety Analysis form for each type of
service prior to any work taking place (Attachment D). The Job Safety Analysis form remains valid for
the length of the project period. The types of services provided by offender workers include 1) Illegal
dump site clean-up, 2) Litter Pick-ups, 3) General Labor.
Additional Terms:
DOC will send a monthly activity report, photo documentation (before and after) of services performed,
and dumpsite invoices (if required) along with the billing statement as requested by the recipient.
CITY OF FEDERAL AY
nature
n �-.�7f"OrJ �9'��ca �✓er��
Printed Name & Title
_ 3Lz1z_o
Date
DEPARTMENT OF CORRECTIONS
Signature of Field Administrator or Work
Release and Residential Program Coordinator
Section 5/CCD
Section/Facility
Date
Please email a copy of this Work Project Description to docclacontracts DOCI.WA.GOV
within two (2) calendar days after it is signed by the second of both Parties. THANK -YOU
State of Washington
Department of Corrections
Attachment A
K12614
�V
starting January 15E. We will make a note of any changes to the rate in your January billing
statement).
PPE, Tools and Equipment Provided by:
Recipient: Will provide any specialty equipment needed to complete specific projects. Will pay for waste
disposal either through providing waste receptacles at the work sites, or at City landfill or transfer
station; dump cards or account information for waste disposal will be provided to DOC Workcrew for
use on City of Federal Way projects if necessary.
Specialty PPE, Tools and Equipment Training Provided by Recipient?
DOC: Will provide Personal Protective Equipment (PPE) and tools and supplies for general litter pick-
up, removal of illegally dumped materials and brush removal, including but not limited to: gloves,
boots rain gear, hard hats, hearing and eye protection, shovels, rakes, trash bags, pickers, surgical
masks, disposable gloves, hand sanitizer, etc.
JSA Worksheet completed and attached?
Recipient will provide the DOC contract manager with a signed Job Safety Analysis form for each type of
service prior to any work taking place (Attachment D). The Job Safety Analysis form remains valid for
the length of the project period. The types of services provided by offender workers include 1) Illegal
dump site clean-up, 2) Litter Pick-ups, 3) General Labor.
Additional Terms:
DOC will send a monthly activity report, photo documentation (before and after) of services performed,
and dumpsite invoices (if required) along with the billing statement as requested by the recipient.
CITY OF FEDERAL NAY
nature
a�- on] den Dfa.�r
Printed Name & Title
Date
DEPARTMENT OF CORRECTIONS
Signa`�f Field Administrator or Work
Release and Residential Program Coordinator
Section 5/CCD
Section/Facility
L
Date
Please email a copy of this Work Project Description to docclacontractsaDCC1. WA. GOV
within two (2) calendar days after it is signed by the second of bath Parties. THANK- YOU
State of Washington
Department of Corrections
Attachment A
K12614
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level: 2
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason.gerwen _ cityoffederalway.com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: rivertz(a).docl.wa.gov
DOC Matrix —Work Project Title: Town Center Litter Cleanup and Landscaping Maintenance
Project Date(s): 12/01/2022-11/30/2023
Project Location(s): Federal Way Town Center Performing Arts & Events Center Contract: K12614
ELEMENTS/ACTIVITIES
SPECIFIC TASKS
HAZARDS
CONTROLS
PPE
PROVIDER of PPE
& TRAIN TO USE
Cutting and removing
Cuts from tools/small
Use proper techniques
DOC
Weed and Brush Removal
Gloves, hard hats,
brush, grass and
machinery
for handling tools, be
boots, equipment -
weeds
aware of
specific safety
surroundings, do not
training
touch sharp blades,
closed -toed shoes,
long pants and long-
Scrapes/Cuts from
sleeved shirts
Be aware of
Boots, gloves, hard
DOC
brush and branches
surroundings, wear
hats
long pants and long-
sleeved shirts
Landscaping
Lifting and moving
Lifting injury
Learn and use proper
Gloves, boots
DOC
plants, soil and
lifting techniques,
landscaping rock
obtain assistance from
other crew members
for heavy or large
items
Use proper techniques
Gloves, hard hats,
DOC
Planting trees, shrubs Cuts from tools/small
and other plants
machinery
for handling tools, be
boots, equipment -
aware of
specific safety
surroundings, do not
training
l
touch sharp blades,
Washington State
K12614
Page 1 of 4
Department of Corrections
Attachment D
Litter removal Picking up litter in the
parking lots and on
the outdoor steps of
the Town Center
property
All Activities
Washington State
Department of Corrections
ciosea-toea snoes,
long pants and long-
sleeved shirts
Fall down stairs
Be aware of
surroundings and
where you step. Step
carefully and hold
handrails when
walking up or down
stairs
Weather— rain/snow Wear appropriate
clothing and footwear
to keep warm and dry
Weather - heat
Wear appropriate
clothing, drink plenty
of fluids, take breaks
in the shade if. possible
Exposure to
Wear appropriate
communicable
clothing, maintain
diseases/pathogens
distance from others
when possible, do not
touch items or people
without proper PPE,
do not work while sick
Be aware of what you
Hand Puncture
are touching, do not
reach into areas you
cannot see
Be aware of
surroundings, have
windows open and
Dust Exposure
allow air -flow to
reduce dust
accumulation in the air
Be aware of
Debris in Eyes
surroundings, work
slowly
Slipping/tripping/falling Watch where you are
walking, step carefully
on or around items
K12614
Attachment D
Rain Coat, boots,
hard hats, gloves
Hard hats
Gloves, surgical
masks or other
face coverings,
boots
Puncture resistant
gloves, litter
pickers
Dust mask, eye
protection
Eye protection
Hard -soled boots
or'rubber boots
DOC
DOC
DOC
DOC
DOC
DOC
DOC
DOC
Page 2 of 4
Lifting items into trucks/vans
Crew Deployment
Travel in vehicles
Placing items into
trucks or vans for
disposal
I
Entering and Exiting
Vehicles
Riding to and from
worksite locations
Traffic noise
Bug bites
Lifting injury
Struck by moving
vehicle
Vehicle accident
Wear long pants and
long sleeved shirts
Learn and use proper
lifting techniques,
obtain assistance from
other crew members
for heavy or large
items
Exit vehicle on the side
of the vehicle away
from the road
suitable for
outdoor work.
Ear plugs DOC
Bug repellant DOC
DOC
Wear high visibility DOC
ANSI Class 2 or 3
safety vests and
hard hats
Work facing oncoming
DOC
traffic
Never enter traffic to
DOC
retrieve equipment
Park vehicle as far off
DOC
the roadway as is safe
Wear high visibility
DOC
clothing, use traffic
cones and emergency
flashers on vehicles
_
Wear seatbelts and
Seatbelts
DOC
remain seated in
moving vehicles at all
times, do not lean out
or stick hands out of
open windows
SPECIAL EQUIPMENT THAT
WORKERS WILL USE
FOR THIS PROJECT:
TASK
HAZARDS TYPE
RISK LEVEL
EQUIPMENT
PROVIDER of SPECIAL EQUIP.
& TRAIN TO USE
Picking up small items
Scrapes/cuts from sharp
objects
Mod
Litter Pickers
DOC
Planting trees/bushes
Scrapes from branches
Low
Shovels, Rakes
-7
DOC
DOC
Leaf cleanup
Slipping on wet leaves
Low
Leaf blower
Washington State K12614 Page 3 of 4
Department of Corrections Attachment D
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
nature) Dale
,VA5or Wv
17/ 'S
(Printed Name) ` Title -biAtzrog—
Department JSA Contact
(Signature)
10/11 /2022
Date
Rene Vertz — Workcrew Program Manager
(Printed Name)
Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: "operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this
point, assume that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result
from each hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity,
emissions, chemicals, low oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing
in the ears and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation,
unconsciousness and even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local
exhaust ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or
minimized with controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 4 of 4
Department of Corrections Attachment D
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level: 2
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason.gerwen@cityoffederalway.com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: rivertz@doc1.wa.gov
DOC Matrix — Work Project Title: Litter Cleanup Project Date(s): 12/01 /2022-11 /30/2023
Project Location(s): Various locations within the City of Federal Way Contract: K12614
ELEMENTS/ACTIVITIES SPECIFIC
HAZARDS
CONTROLS
PPE
PROVIDER of
TASKS
PPE & TRAIN TO
USE
Litter removal
Picking up litter on
Weather— rain/snow
Wear appropriate clothing Rain Coat, boots,
DOC
the side of the
and footwear to keep warm hard hats, gloves
road
and dry
Weather - heat
Wear appropriate clothing,
Hard hats
DOC
drink plenty of fluids, take
breaks in the shade if
possible
Exposure to
Wear appropriate clothing,
Gloves, surgical
DOC
communicable
maintain distance from
masks or other
diseases/pathogens
others when possible, do not
face coverings,
touch items or people
boots
without proper PPE, do not
work while sick
Be aware of what you are
Puncture
DOC
Hand Puncture
touching, do not reach into
resistant gloves,
areas you cannot see
litter pickers
Dust mask, eye
_
DOC
Be aware of surroundings,
Dust Exposure
have windows open and
protection
allow air -flow to reduce dust
accumulation in the air
Debris in Eyes
Be aware of surroundings, Eye protection
DOC
work slowly
Washington State K12614 Page 1 of 3
Department of Corrections Attachment D
Slipping/tripping/falling
Watch where you are Hard -soled boots
DOC
walking, step carefully on or or rubber boots
around items suitable for
outdoor work.
Traffic noise
Ear plugs
DOC
Wear long pants and long
Bug repellant
DOC
Bug bites
sleeved shirts
Lifting items into trucks/vans Placing items into Lifting injury
Learn and use proper lifting
DOC
trucks or vans for
techniques, obtain assistance
disposal
from other crew members for
heavy or large items
Exit vehicle on the side of the
Wear high
DOC
_
Crew Deployment Entering and Exiting Struck by moving
Vehicles vehicle
vehicle away from the road
visibility ANSI
Class 2 or 3
safety vests and
Work facing oncoming traffic
hard hats
DOC
Never enter traffic to retrieve
DOC
equipment
Park vehicle as far off the
DOC
roadway as is safe
DOC
_
Wear high visibility clothing,
use traffic cones and
emergency flashers on
vehicles
Wear seatbelts and remain
Seatbelts
Travel in vehicles
Riding to and from
Vehicle accident
DOC
worksite locations
seated in moving vehicles at
all times, do not lean out or
stick hands out of open
windows
SPECIAL EQUIPMENT THAT WORKERS WILL USE
FOR THIS PROJECT:
TASK
HAZARDS TYPE
RISK LEVEL
EQUIPMENT
PROVIDER of SPECIAL EQUIP.
& TRAIN TO USE
Picking up piles of garbage Scrapes/cuts from hidden
Mod
Shovels, Rakes
_
DOC
sharp objects
Picking up small items
Scrapes/cuts from sharp
Mod
Litter Pickers
DOC
objects
Washington State K12614 Page 2 of 3
Department of Corrections Attachment D
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
3 z a�z3
i ature) D to
JASaJ N v 444cs
(Printed Name) Title I
31144ap _
Department JSA Contact
(Signature)
r 10/11/2022
Date
Rene Vertz — Workcrew Program Manager
(Printed Name)
Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: "operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this point,
assume that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result from each
hazard.)
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity, emissions,
chemicals, low oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing in the
ears and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation, unconsciousness and
even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local
exhaust ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or minimized with
controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 3 of 3
Department of Corrections Attachment D
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level: 2
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email Jason.gerwen@cityoffederalway.com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: rivertz doc1.wa.gov
DOC Matrix — Work Project Title: Illegal Dumpsite Cleanup Project Date(s): 12/01/2022-11/30/2023
Project Location(s): Various locations within the City of Federal Way Contract: K12614
ELEMENTS/ACTIVITIES
Illegal dumpsite cleanups
Washington State
Department of Corrections
SPECIFIC
TASKS
Picking up litter,
furniture and other
items illegally
dumped in areas
around the City
HAZARDS I CONTROLS
Weather— rain/snow
Weather - heat
Exposureto
communicable
diseases/pathogens
Hand Puncture
Dust Exposure
Debris in Eyes
Wear appropriate clothing
and footwear to keep warm
and dry
Wear appropriate clothing,
drink plenty of fluids, take
breaks in the shade if possible
Wear appropriate clothing,
maintain distance from others
when possible, do not touch
items or people without
proper PPE, do not work while
sick
Be aware of what you are
touching, do not reach into
areas you cannot see
Be aware of surroundings,
have windows open and allow
air -flow to reduce dust
accumulation in the air
Be aware of surroundings,
work slowly
K12614
Attachment D
PPE
Rain Coat, boots,
hard hats, gloves
Hard hats
PROVIDER of
PPE & TRAIN TO
USE
DOC
I
DOC
Gloves, surgical DOC
masks or other
face coverings,
boots
Puncture DOC
resistant gloves,
litter pickers
Dust mask, eye DOC
protection
Eye protection DOC
Page 1 of 3
Lifting items into trucks/vans Placing items into
ktrucks or vans for
disposal
Travel in vehicles
Slipping/tripping/falling Watch where you are walking, Hard -soled boots DOC
step carefully on or around or rubber boots
items suitable for
outdoor work.
Traffic noise Ear plugs DOC
Bug bites Wear long pants and long Bug repellant DOC
sleeved shirts
Lifting injury
Entering and Exiting Struck by moving
Vehicles vehicle
Riding to and from Vehicle accident
worksite locations
Learn and use proper lifting
techniques, obtain assistance
from other crew members for
heavy or large items
Exit vehicle on the side of the
vehicle away from the road
Work facing oncoming traffic
Never enter traffic to retrieve
equipment
Park vehicle as far off the
roadway as is safe
Wear high visibility clothing,
use traffic cones and
emergency flashers on
vehicles
Wear seatbelts and remain
seated in moving vehicles at
all times, do not lean out or
stick hands out of open
windows
SPECIAL EQUIPMENT THAT WORKERS WILL USE FOR THIS PROJECT:
TASK I HAZARDS TYPE I RISK LEVEL 11 EQUIPMENT
Picking up piles of garbage
Picking up small items
Cutting brush/blackberries
Washington State
Department of Corrections
Scrapes/cuts from hidden
sharp objects
Scrapes/cuts from sharp
objects
Scrapes/cuts from thorns
Mod
Mod
Mod '
K12614
Attachment D
Shovels, Rakes
DOC
Wear high DOC
visibility ANSI
Class 2 or 3
safety vests and
hard hats
DOC
OX0
DOC
DOC
Seatbelts DOC
PROVIDER of SPECIAL EQUIP.
& TRAIN TO USE
DOC
Litter Pickers I DOC
Pruners I DOC
Page 2 of 3
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
nature) Date
JAs0t3 �� c7 V,&?A09-5
(Printed Name) Title -z>J se —
Department JSA Contact
(Signature)
10/11/2022
Date
Rene Vertz — Workcrew Program Manager
(Printed Name)
Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: 'operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this
point, assume that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result
from each hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity,
emissions, chemicals, low oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing
in the ears and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation,
unconsciousness and even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local
exhaust ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or
minimized with controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 3 of 3
Department of Corrections Attachment D
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level: 1, 2 and 3
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason. erwen cit offederalwa .com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: rovertz doc1.wa. ov
DOC Matrix — Work Project Title: General Labor Project Date(s): 12/01/2022-11/30/2023
Project Location(s): Various locations within the City of Federal Way Contract: K12614
ELEMENTS/ACTIVITIES SPECIFIC HAZARDS
TASKS
Weed and Brush Removal
Landscaping
Landscaping continued
Trail Construction
Cutting and
removing brush,
grass and weeds
Weed eating
Lifting and moving
plants, soil and
landscaping rock
Planting trees,
shrubs and other
plants
Cutting and
removine brush
Cuts from tools/small
machinery
Scrapes/Cuts from
brush and branches
Cuts from tools/small
machinery
Lifting injury
Cuts from tools/small
machinery
Cuts from tools/small
machinery
CONTROLS
Use proper techniques for
handling tools, be aware of
surroundings, do not touch sharp
blades, closed -toed shoes, long
pants and long-sleeved shirts
Be aware of surroundings, wear
long pants and long-sleeved shirts
Use proper techniques for
handling tools, be aware of
surroundings. do not touch share
bla
pa i
Lei
tec
fro
hey
Us1
hai
Sul
bla
pai
Us
ha
PPE
PROVIDER of
PPE & TRAIN
TO USE
Gloves, hard
DOC
hats, boots,
equipment -
specific safety
training
Boots, gloves,
DOC
hard hats
Gloves, hard
hats, boots,
eauioment-
DOC
Washington State K12614 Page 1 of 4
Department of Corrections Attachment D
Wood Chipping
Carpentry/Construction
All activities
Disposal of
branches and
other wood
products with a
chipping machine
Putting together
and repairing
small structures
and furniture
Cuts/injuries from
machinery
Lifting injury
Cuts/injuries from saws
and other machinery
Dust/Debris Exposure
to eyes and mouth
Weather — rain/snow
Weather - heat
Exposure to
communicable
diseases/pathogens
Hand Puncture
Dust Exposure
surroundings, do not touch sharp
blades, closed -toed shoes, long
` pants and long-sleeved shirts,
Use proper techniques for
handling tools, be aware of
surroundings, do not touch sharp
blades, closed -toed shoes, long
pants and long-sleeved shirts,
Learn and use proper lifting
techniques, obtain assistance
from other crew members for
heavy or large items
Use proper techniques for
handling tools, be aware of
surroundings, do not touch sharp
blades, closed -toed shoes, long
pants and long-sleeved shirts,
Be aware of surroundings, have
windows open and allow air -flow
to reduce dust accumulation in
the air, work slowly and carefully
Wear appropriate clothing and
footwear to keep warm and dry
Wear appropriate clothing, drink
plenty of fluids, take breaks in the
shade if possible
Wear appropriate clothing,
maintain distance from others
when possible, do not touch
items or people without proper
PPE, do not work while sick
Be aware of what you are
touching, do not reach into areas
you cannot see
Be aware of surroundings, have
windows open and allow air -flow
to reduce dust accumulation in
the air
equipment -
specific safety
training
Gloves, hard
hats, boots,
equipment -
specific safety
training
Gloves, boots
DOC
DOC
Gloves, hard DOC
hats, boots,
equipment -
specific safety
training
Dust mask, eye DOC
protection
Rain Coat, DOC
boots, hard
hats, gloves
Hard hats DOC
Gloves, surgical DOC
masks or other
face coverings,
boots
Puncture DOC
resistant gloves,
litter pickers
Dust mask, eye I DOC
protection
Washington State K12614 Page 2 of 4
Department of Corrections Attachment D
Debris in Eyes
Be aware of surroundings, work
slowly
Watch where you are walking,
Eye protection
DOC
Slipping/tripping/falling
Hard -soled
DOC
step carefully on or around items
boots or rubber
boots suitable
for outdoor
work.
Traffic noise
Ear plugs
DOC
Bug bites
Wear long pants and long sleeved
Bug repellant
DOC
shirts
Lifting items into trucks/vans Placing items into
Lifting injury Learn and use proper lifting
DOC
trucks or vans for
techniques, obtain assistance
disposal
from other crew members for
heavy or large items
_
Wear high DOC
Crew Deployment
Entering and
Struck by moving
Exit vehicle on the side of the
Exiting Vehicles
vehicle
vehicle away from the road
visibility ANSI
Class 2 or 3
safety vests and
hard hats J
DOC
Work facing oncoming traffic
Never enter traffic to retrieve
DOC
equipment
Park vehicle as far off the
DOC
roadway as is safe
Wear high visibility clothing, use
DOC
traffic cones and emergency
flashers on vehicles
Travel in vehicles
Riding to and from
Vehicle accident
Wear seatbelts and remain
Seatbelts
DOC
worksite locations
seated in moving vehicles at all
times, do not lean out or stick
hands out of open windows
SPECIAL EQUIPMENT THAT
WORKERS WILL USE
FOR THIS PROJECT:
TASK
HAZARDS TYPE
RISK LEVEL
EQUIPMENT
PROVIDER of SPECIAL EQUIP.
_ & TRAIN TO USE
DOC
Weed eating
Cuts from tools/small
Moderate
Gas or electric weed eaters
machinery
Cuts from tools/small
DOC
Cutting and removing brush
Moderate
Clippers, pruners
machinery
Washington State K12614 Page 3 of 4
Department of Corrections Attachment D
Disposal of branches and
Cuts/injuries from
Moderate
Wood chipper
City of Federal Way
other wood products with a
machinery
chipping machine
_
Cutting brush/blackberries
Scrapes/cuts from thorns
Low
Clippers, Pruners
DOC
Planting trees/bushes
Scrapes from branches
Low
Shovels, Rakes
DOC
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
l
3 aaoa3
(Sign ure) D to
-J_A�r3 �- i Pars
(Printed Name) Title ��l�EG7ro�—
Department JSA Contact
(Signature)
10/11 /2022
Date
Rene Vertz — Workcrew Program Manager
(Printed Name) Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: "operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this point, assume
that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result from each hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion,' noise, electricity, emissions, chemicals, low
oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing in the ears
and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation, unconsciousness and even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local exhaust
ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or minimized with controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 4 of 4
Department of Corrections Attachment D
RETURN TO EXT:
AUTUMN GRESSETT 6914
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
ORIGINATING DEPT./DIV: PRCS/PAEC
2. ORIGINATING STAFF PERSON: AUTUMN GRESSETT
EXT: 6914
DATE REQ. BY: ASAP
TYPE OF DOCUMENT (CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ)
❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT
❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG
❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G BOND RELATED DOCUMENTS)
❑ ORDINANCE ❑ RESOLUTION
❑ CONTRACT AMENDMENT (AG#): ❑ INTERLOCAL
R OTHER WA DEPARTMENT OF CORRECTIONS MASTER AGREEMENT- CLASS V COMMUNITY RESTITUTION PROGRAMS
5. PROJECT NAME: CLASS V COMMUNITY RESTITUTION PROGRAMS
0
NAME OF CONTRACTOR: STATE OF WASHINGTON, DEPARTMENT OF CORRECTIONS, WESTERN WASHINGTON WORKCREW
ADDRESS: 851 POPLAR PLACE SOUTH
E-MAIL: RJVERTZ@DOCI-WA-GOV
SIGNATURE NAME:
MS: T13-76, SEATTLE, WA 98144
TELEPHONE
FAX: 206-720-342E
TITLE
206-726-6719
7. EXHIBITS AND ATTACHMENTS: o SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL
OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS
8. TERM: COMMENCEMENT DATE:
COMPLETION DATE: JUNE 30, 2023
TOTAL COMPENSATION $ up to $75,000 per year (INCLUDE EXPENSES AND SALES TAX, IF ANY)
(IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED
❑ YES LINO IF YES, $,
RETAINAGE: RETAINAGE AMOUNT:
PAID BY. ❑ CONTRACTOR ❑ CITY
❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDEE
❑ PURCHASING: PLEASE CHARGE TO: W pm-o �'lv K
YV it V;t On e&P, Involz
10. DOCUMENT/CONTRACT REVIEW IN [TIAL / DATE REVIEWED INITIAL 1 DATE APPROVED
W PROJECT MANAGER AG 11/12/2021
❑ DIRECTOR
❑ RISK MANAGEMENT (IF APPLICABLE)
O LAW
H. COUNCIL APPROVAL (IF APPLICABLE)
12. CONTRACT SIGNATURE ROUTING
JE 11/15/21
SCHEDULED COMMITTEE DATE: COMMITTEE APPROVAL DATE: 11/23/2021
SCHEDULED COUNCIL DATE: COUNCIL APPROVAL DATE: 12/7/2021
❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D:
❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
❑ CREATE ELECTRONIC REMINDER/NOTIFICATION FOR 1 MONTH PRIOR TO EXPIRATION DATE
(Include dept. support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.)
TNI'TIAL / DATE SIGNED
❑ LAW DEPARTMENT
SIGNATORY (MAYOR OR DIRECTOR)
❑ CITY CLERK
❑ ASSIGNED AG# AVG# Rp'0i
❑ SIGNED COPY RETURNED DATE SENT: (o.
COMMENTS:
1 /1 n9 R
Class V Restitution, Work Release, and Community Supervision or Custody
Master Agreement
Between
THE WASHINGTON STATE DEPARTMENT OF CORRECTIONS
And
CITY OF FEDERAL WAY
This Master Contract Agreement is entered into by and between the Washington State Department of
Corrections, hereinafter referred to as "DOC," and, City of Federal Way, located at 33325 81h Ave. S.
Federal Way, WA 98003, hereinafter referred to as the "RECIPIENT OF THE SERVICES" or
"RECIPIENT." Legal authority for this Master Contract Agreement is pursuant to RCW 72.09.100 and
Chapter 137-80 WAC.
Individuals who provide services under this Master Agreement reside in the community and are also
known as 'Workers'. For the provision of services under this Master Agreement, all Workers are under
Department, Federal, City, and/or County jurisdiction.
1. PURPOSE
The purpose of this Agreement is to provide the master terms and conditions between the Parties for
Workers to provide work crew services to the RECIPIENT. Eligibility to receive services is defined in
WAC 137-80. No public employees will be displaced as a result of this Agreement.
On December 1, 2020, and after the execution of a new Master Agreement, the terms and conditions
contained in this Master Agreement will replace and terminate any previous Work Crew Agreement and
Work Project Descriptions between the Parties. For this Master Agreement to be valid it must be signed
by the DOC Contracts Administrator or designee on behalf of DOC.
2. WORK PROJECT DESCRIPTIONS
Work crew projects are limited to those that can be properly supervised as determined by the DOC Field
Administrator, Work Release and Residential Program Administrator, or designee and the RECIPIENT's
Contract Manager. Each project is subject to careful review for security requirements. Each distinct
project requires a separate Work Project Description that is signed by both Parties to this Agreement. [See
Attachment A] The Work Project Description will detail the work to be done, the cost to the RECIPIENT
and other specifics of the particular project.
A Field Administrator or Work Release and Residential Program Administrator is authorized to sign
Work Project Descriptions on behalf of DOC. A Work Project Description may be valid for up to one year
but must end prior to, or on the same date as, this Master Contract Agreement. All services provided
under each signed Work Project Description shall be performed pursuant to the terms of this Master
Agreement.
3. TERM
The term of this Master Contract Agreement shall begin July 01, 2021 and continue through June 30, 2023,
unless terminated sooner as provided for herein.
4. BILLING and PAYMENT
In consideration of the services provided hereunder, payment to DOC will be as follows:
State of Washington K12614 Page 1 of 6
Department of Corrections 21RCP
A. DOC will invoice the RECIPIENT for payment by the 20th of the month following each month in
which services were provided. Invoices for payment will include all direct and indirect charges
payable to DOC by the RECIPIENT that were negotiated between the Parties.
B. Payment by the RECIPIENT, will be due to the DOC address indicated below within 30 calendar
days of the date of the invoice. This DOC Master Agreement number and the location of the
project for which payment is made must be included with each payment.
C. DOC will pay the Department of Labor and Industries (L&I) all workers' compensation
premiums due under Title 51 RCW for workers providing services under this agreement.
1) Recipients must pay the department for all such workers' compensation premiums under
Title 51 RCW.
2) DOC will report, each quarter, for services provided to the RECIPIENT during the previous
quarter, to L&I the total number of hours worked under this agreement and pay the total cost
due for workers' compensation coverage directly to L&I for those hours.
D, Addresses to use for Billing and Payment.
1) Billing - Invoices for payment will be mailed to the address provided by the RECIPIENT:
City Of Federal Way
Attn: Autumn Gressett, Parks Department
33325 8th Ave. S.
Federal Way, WA 98003
2) Payment
a. State Agencies Only - will pay using the following statewide vendor number:
SWV0003872-01 [IAP Payment - DOC General Account]
b. All Other RECIPIENTS - will send payment to the address provided by the DOC
Community Corrections location from which services were provided.
5. TERMINATION
When in its own best interest, either party may terminate this Agreement, in whole or in part, upon 30
days' written notice to the other party, beginning on the second day after mailing such notice. If this
Agreement is so terminated each of the Parties shall be liable only in accordance with the terms of this
Agreement for services rendered prior to the effective date of termination.
6. HAZARD ASSESSMENT AND MITIGATION
A. In accordance with the Statewide Safety Program, work generally considered to be dangerous or
hazardous may not be performed by Workers under this agreement, (See Attachment C, Prohibited
Work)
B. Before Workers provide services at any new and distinct project location, the RECIPIENT and DOC
will jointly perform a written hazard, safety and security assessment.
C. The Assessment must be performed in accordance with WAC 296-800-160 (See Attachment D, Sample
Job Safety Analysis Worksheet).
State of Washington K12614 Page 2 of 6
Department of Corrections 21RCP
D. After the Assessment DOC may 1) agree to the specialized PPE that the Recipient will provide to
workers to mitigate the effects of identified hazard(s); 2) request that the Recipient remove or
otherwise mitigate some or all of the hazards before workers perform the contracted work; or 3)
withdraw from the project.
E. The RECIPIENT will inform DOC promptly, in writing, if hazardous conditions or materials are
found at the project site. If hazardous conditions or materials are discovered while Workers are
working at RECIPIENT's site, then work will be suspended immediately and RECIPIENT will make
appropriate regulatory notifications and request further assessment.
7. TOOLS, EQUIPMENT AND SUPPLIES
Aside from the basic work attire, PPE, and SSE provided per DOC policy, the specific tools, equipment
and supplies necessary for each project, and the party to the Agreement responsible for providing each
item, will be designated in the Work Project Description and JSA for that project.
8. TRAINING
A. The RECIPIENT will train Workers regarding the work to perform as well as any safety
requirements specific to the project site and in the use of any specialized equipment.
B. For work performed in one static location, RECIPIENT will provide project and site specific
safety, equipment, and PPE training as well as instruction in the use of any specialized
equipment. The RECIPIENT will provide such training and instruction on the first day of each
new project and again if and whenever the work changes to involve tasks or equipment for
which the recipient has not trained the workers.
C. For the same types of Level one or Level two work performed at successive locations, the
RECIPIENT must provide the required training and instruction, described in Section 9(B) above,
on the first day of work and again if and whenever the work changes to involve tasks or
equipment for which the recipient has not trained the workers.
D. The RECIPIENT will ensure that all safety training is in compliance with all applicable laws and
regulations including, but not limited to, Division of Occupational Safety and Health (DOSH)
regulations and the Washington Industrial Safety and Health Act (WISHA).
E. Training provided by RECIPEINT can be in a variety of forms including, but not limited to, video,
audio, electronic, Power Point, and/or printed instruction with illustrations. RECIPIENT
provided training may be administered by DOC but source material shall be provided by the
RECIPIENT. DOC has the sole discretion to supplement training provided by the RECIPIENT.
9. CONTRACT MANAGEMENT
The contract manager(s) for each of the Parties shall be responsible for and shall be the contact person(s)
for all communications regarding the performance of this Agreement. Either party may, with written
notice to the other, designate different contact persons.
RECIPIENT: Jason Gerwen, 253.835.6962 J a S 6 Qr we n C-1 C i``'lrj o f - ,rd-eroL I w aj torn wl(e! te-
DOC: Rene Vertz, Program Manager, 206.726.6719, �jvertz@?docl.wa.gov
10. SUPERVISION & TRANSPORATION
A. The Work: Work level definitions are found in the Class V Project Matrix, attached hereto and
incorporated by reference as Attachment B. The following are supervision requirements
pertaining to the Work Project Levels:
State of Washington K12614 Page 3 of 6
Department of Corrections 21RCP
1) For Level 1 and 2 Work Projects:
DOC will supervise the work performed, in conformance with training provided by
RECIPIENT in accordance with Section 8 above, and maintain daily oversight of the project
until completed.
2) For Level 3 Work Projects:
RECIPIENT will supervise the work performed by workers, in conformance with training
provided by RECIPIENT in accordance with Section 8 above, and maintain daily oversight of
the project until completed.
B. Security: For all work project levels, a Correctional Officer will be present to provide for the
security and custody of Workers and the safety of the public at large.
C. On -Site Illness/Accidents: A first aid qualified Correctional Officer will be present at the worksite
at all times. In the event of DOC Individual illness or injury, DOC will provide the appropriate
first aid. If necessary, and as available, emergency medical assistance will be called, or the
Individual will be transported to the nearest medical facility for treatment.
1) Expenses:
a) Illness. DOC will pay all expenses related to treatment of DOC Individual illness.
b) Injury The cost of treatment provided to Workers beyond first aid for any and all
work related injuries will be paid in accordance with Title 51 RCW.
c) The DOC's L&I Account Number, 439,048-21, will be the account number used by
Workers, DOC and medical providers when reporting work related injury.
D. Transportation: DOC has sole responsibility to transport of Workers to and from the work project
site.
11. PUBLIC RELATIONS
Neither party shall arrange for media coverage without the consent of the other party, nor shall either
party release information to the media without the consent of the other party. This includes, but is not
limited to any reference in print, television, and social media without the consent of the other party.
12. WORK PRODUCT and PERFORMANCE
Washington State and DOC, including its agents and/or employees:
A. Are not responsible for, and do not guarantee, the quality of the work performed or products
produced by work crews;
B. Shall not be required to pay other workers to re -do or repair the work performed by work
crews; and
C. Are not responsible for damages to third parties resulting from the work performed or
products produced by work crews.
D. The Recipient will pay all costs agreed to for services rendered under this Agreement,
regardless of the quality of the work performed or products produced by the workers.
13. INDEMNIFICATION
A. RECIPIENT, its agents, and/or employees:
State of Washington K12614 Page 4 of 6
Department of Corrections 21RCP
1) Are responsible for any damages resulting from the negligence of the RECIPIENT, its
agents, and/or employees; and
2) Will indemnify, defend, and hold harmless DOC for claims arising from the negligent
acts or omissions of the RECIPIENT, its agents, and/or employees.
B. DOC, its agents, and/or employees:
1) Are responsible for damages that arise out of DOC, its agents, and/or employees'
negligent security supervision of Workers.
C. In accordance with the laws of the state of Washington and to the extent permitted by law, if
both Parties to this Agreement are negligent and jointly liable, each party will assume
responsibility for its own negligent acts or omissions.
14. DISPUTES
In the event that a dispute arises under this Agreement, it shall be determined by a Dispute Board in the
following manner: Each party to this Agreement shall appoint one member to the Dispute Board. The
members so appointed shall jointly appoint an additional member to the Dispute Board. The Dispute
Board shall review the facts, Agreement terms and applicable statutes and rules and make a
determination of the dispute. The Dispute Board shall thereafter decide the dispute with the majority
prevailing.
15. INSURANCE
A. RECIPIENT shall maintain insurance coverage in full force and effect during the entire term of
this Contract as set out below. The insurance required shall be issued by an insurance company
authorized to do business within the state of Washington, and shall name the state of
Washington, its agents and employees as additional insureds. All policies shall be primary to any
other valid and collectable insurance. RECIPIENT shall instruct the insurers to give the
Department 30 days advance notice of any insurance cancellation.
B. Commercial Form General Liability Insurance (contractual liability included) with minimum
limits of $1,000,000.00 for each occurrence and $2,000,000.00 for general aggregate. If the
insurance is written on a claims -made form, it shall continue for three (3) years following
termination of this Contract. The insurance shall have a retroactive date of placement prior to or
coinciding with the commencement of the Term of this Contract
C. Except where further described in this Agreement, RECIPIENT will at all times comply with all
applicable workers' compensation, occupational disease, and occupational health and safety
laws, statutes, and regulations to the full extent applicable. The State will not be held responsible
in any way for claims filed by the RECIPIENT or their employees for services performed under
the terms of this Contract.
D. RECIPIENT will provide the DOC with proof of current insurance for each coverage required
under the Contract. Such proof shall be sent to Washington State Department of Corrections,
Contracts and Legal Affairs at docclacontractsC�docl.wa. ov . Contractor shall immediately notify
Contracts and Legal Affairs in the event such policy is terminated, canceled, or modified.
16. PUBLIC BENEFIT NON-PROFIT
In order to utilize work crew services, RECIPIENTS that are non -profits, must be public benefit non-
profits, as defined by the federal Internal Revenue Service (IRS). Those that are public benefit non -profits
State of Washington K12614 Page 5 of 6
Department of Corrections 21RCP
must provide proof to DOC of official IRS designation as a (501(c)(3) Charitable Organization or a
(501(c)(4) Social Welfare Organization.
The RECIPIENT must provide DOC with proof of its IRS public benefit non-profit designation, by
providing to the Contract Manager listed in Section 9, CONTRACT MANAGEMENT, above.
17. AMENDMENTS AND MODIFICATIONS
Amendments or modifications to this Agreement shall not be binding unless agreed to in writing by the
Parties hereto prior to such change or modification. Only the DOC Secretary or designee has the authority
to alter, amend, modify, or waive any clause or condition of this Agreement for DOC,
18, WAIVER
Waiver of any default or breach shall not be deemed a waiver of any subsequent default or breach. Any
waiver shall not be construed to be a modification of the terms of this contract unless stated to be such in
writing and signed by authorized representative of the Department.
19. SEVERABILITY
The terms and conditions of this Agreement are severable. If any term or condition of this Contract is held
invalid by any court, such invalidity shall not affect the validity of the other terms or conditions of this
Agreement.
20. ENTIRE AGREEMENT
This Agreement, including referenced Attachments, represents all the terms and conditions agreed upon
by the Parties. No other understanding or representations, oral or otherwise, regarding the subject matter
of this Agreement shall be deemed to exist or to bind any of the Parties hereto. As used herein, reference
to the Agreement shall include this Master Agreement, fully executed amendments to this Agreement,
and any Work Project Descriptions executed and attached hereto.
THIS Agreement, consisting of six (6) pages and four (4) attachments, is executed by the persons signing
below who warrant that they have the authority to execute the Agreement.
CITY OF FEDERAL WAY
(5, tore)
(Printed Name)
Mayor
(Title)
1 �-
(Date)
DEPARTMENT OF CORRECTIONS
Digitally signed by
Huntsinger,
Huntsinger, Daryl A. (DOC)
Daryl A. (DOC) 08,00'022.02.1113:54:14
(Signature)
Daryl A. Huntsinger
(Printed Name)
Contracts Administrator
(Title)
Z/ it 0ZZ
(Date)
State of Washington K12614 Page 6 of 6
Department of Corrections 21RCP
( gnat re}
04tft�
.S�i"� � a Cotcr�'new
(Printed Name)
City Clerk
(Title)
June 11, um,
(Date)
(Signature)
3 -IM A
(Printed Na )
City Attorney
(Title
-loZ.
(Date
Approved as to Form
By: John C. Dittman, Assistant Attorney General
Date: December 29, 2020
State of Washington K12614 Page 7 of 6
Department of Corrections 21RCP
WASHINGTON STATE DEPARTMENT OF CORRECTIONS
Community Corxections Division
CLASS V Work Project Description
Contract Number; K12614
Recipient; City of Federd Way
Recipient is; ❑C Government Entity ❑ State Agency] Public Benefit Nonprofit & Evidence
Attached ❑
Recipient Contact; 14Lon GeLvLe Phone; 253-835-8962 - Email;jason,gerwen@cityoffedel_aiyaay.com
Department Contact; R nee Vertz Phone: 206-286-327 Email; riyertz@docLwa.g_ov
Work Project Title; 0tV qfFedgral hLayTarlcs & Reo e t' yt Qelpartment
Project Level; ®1 M 2 ® 3
Workers will.; Provide litter pick -ups, -illegal dumping site clean-ups, and general labor on property
owned by the City of Federal Way as outlined in the Statement of Work attached (Attachment E),
Workers will not perform any work listed In the Prohibited Work document (Attachment C).
Number of Workers on crew: Minim af:Z
Project Location: Various worksites in the City of Federal Way
Project Period (One year maximum): Decombeg, L 2021, through November 30 2022
1. Projected Total Number of Crew Hours, Number of Workers; N/A
2. Minimums for Set Monthly Rate and/or Full or Half Day Rate: N/A
3, Approximate Work Hours: Arrive at ao a;,m, Depart at 2;30 p,m,
Special Payment Terms, Recipient will pay DOC:
1, Service Maximum: City of Federal Way will pay DOC a maximum of $75,000 for services provided
per year,
2. Invoice: DOC will invoice city of Federal Way for worker services at the rate of J251dgy_per
person (workers + supervisors), Each dated and itemized invoice to City of Federal Way will
include: Agreement #K12614, dates and hours of services provided, description of the work, and
the amount of'payment due,
3. Administrative and program overhead at 10% of the actual inontllly billing which will cover the
cost of miscellaneous expenditures needed for the specified contract work with the City of
Federal kVay, Expenditures include, but are not limited to, office supplies, hand tools, shovels,
rakes, litter pickers, garbage bags, sharps containers, gloves arld boots,
4. Vehicle operation costs for assigned time on City of Federal Way's contracts work;
reimbursement at the current privately -owned vehicle mileage rate (as determined by OFM), The
current rate can bb located at litlmdofm,wa."avlaccn;intl I��i�l silt `az iivc'-accou� fling-
re ounces '.,a el.
5, L&I Premiums: Reimbursement for worker L&I premiums at the current DOC L&I rate, The rate
for 2021-is $0.3669 Der workerper _hoLtr. (This rate potentially changes every year on January 19t,
so Work Project Descriptions that overlap years may have changes to this rate on our invoices
starting January Vt. We will make a note of any changes to the rate in your January billing
statement),
State of Washington - Attachment A Page 1 of 2
Department of Corrections K12614
PPE, Tools and Equipment Provided by:
Recipient: Will provide any specialty equipment needed to complete specific projects. Will pay for waste
disposal either through providing waste receptacles at the work sites, or at City landfill or transfer
station, dump cards or account information for waste disposal will be provided to DOC Workcrew for
use on City of Federal Way projects if necessary.
Specialty PPE, Tools and Equipment Training Provided by Recipient? 17
DOC: Will provide Personal Protective Equipment (PPE) and tools and supplies for general litter pick-
up, removal of illegally dumped materials and brush removal, including but not limited to: gloves,
boots rain gear, hard hats, hearing and eye protection, shovels, rakes, trash bags, pickers, surgical
masks, disposable gloves, hand sanitizer, etc.
JSA Worksheet completed and attached?
Recipient will provide the DOC contract manager with a signed Job Safety Analysis form for each type of
service prior to any work taking place (Attachment D). The Job Safety Analysis form remains valid for
the length of the project period. The types of services provided by offender workers include 1) Illegal
dump site clean-up, 2) Litter Pick-ups, 3) General Labor,
Additional Terms:
DOC will send a monthly activity report, photo documentation (before and after) of services performed,
and dumpsite invoices (if required) along with the billing statement as requested by the recipient.
>1"A"
Printed Name & Title
Date
DEPARTMENT OF CORRECTIONS
9 ; A.N- L�� /,-
SignatUre of Field Administr tar or Work
Release and Residential Program Coordinator
Section 5/CCD
Section/Facility
Date
Please email a copy of this Work Project Description to docclacontracts _DOC 1. WA. GOV
within two (2) calendar days after it is signed by the second of both Parties. THANK -YOU
State of Washington Attachment A Page 1 of 2
Department of Corrections K12614
PROJECT TITLES
LEVEL THREE PROJECTS
CUTTING FIREWOOD
ATTACHMENT B
Department of Corrections
CLASS V PROJECT MATRIX
PROJECT DESCRIPTIONS
Labor intensive. Arduous work, difficult terrain and all types of weather. Operating and maintaining tools and
equipment such as chainsaws. Handling of fuel for motors. Heavy lifting of timber, logs, rocks, etc. is required.
NOXIOUS WEED Small infestations may be eradicated mechanically, manually or with a pre -approved herbicide. Methods of
REMOVAL mechanical control include pulling, hoeing, mowing, line trimmers, and tillage. Very effective for annual weeds but
can be very expensive for large areas when done with hand labor. Hand labor methods are most often used for very
small infestations, in environmentally sensitive areas or where difficult terrain or obstructions such as sign posts,
guard rails and fences prevent the use of other equipment.
BRUSH CLEARING Underbrush consists of low growing shrubs, bushes, wild grasses and weeds, examples include scotch broom &
blackberries. Clearing brush may expose workers to poison oak, brambles, snakes or other natural hazards. Hand
tools such as pruners, clippers, weed eaters and mowers may be used. Work is differentiated from other grounds
work by use of heavier equipment including: "brush hogs".
CARPENTRY / Building, installing, and repairing structures, fixtures, furniture, and other items using different types of materials
CONSTRUCTION including wood and steel. Requires working with instructions and schematics from supervisors and utilizing hand and
power tools.
STREAM ENHANCEMENT Benefits the environment and water quality. Requires use and maintenance of specialized tools and equipment like
& RESTORATION chainsaws. Requires specialized safety training for terrain and weather conditions, handling of fuel and placement of
large rocks to keep stream banks from eroding. Work requires heavy lifting of timber, logs, rocks, etc.
WOOD CHIPPING Workers haul limbs, trunks, branches, and a variety of wood debris to a wood chipper. Workers use the resulting
chips in compost mixtures and for landscaping,
FORKLIFT OPERATION Forklift operators use machinery to transport various objects at work sites or warehouses, this position requires
training and certification prior to independent operation. Due to the nature of the position in working with equipment,
this position requires an increased awareness of the surrounding area for safety of persons and property.
LEVEL TWO PROJECTS
I BRIDGE CONSTRUCTION
Washington State
Department of Corrections
Work is usually in parks and other natural areas where trails and bridges are in need of repair or upgrade. Terrain
Attachment B Page 1 of 2
FOR TRAILS
may be difficult. Work involves taking measurements, laying foundations, digging, building up ground, laying planks
for treading and utilizing hand and power tools.
SALMON RESTORATION
Work is normally performed at a fish hatchery and in its ecosystem of pools, ponds, tanks, streams and the
surrounding woods/forest environment. Clipping fins is a basic function and is utilized for marking the fish to indicate
hatchery origin.
Work such as brush clearing, stream restoration, introducing fish by-products into water sources to achieve nutrient
enhancement.
TREE PLANTING
Workers transplant tree seedlings, generally for forestry, reclamation or to prevent streambank erosion. Workers
carry sacks of seedlings, utilize hand tools and must navigate rough terrain.
TRAIL CONSTRUCTION
Workers use a variety of hand tools to restructure trails and pathways. Work may include trail drainage, surfacing
with a variety of materials (i_e., stone, woodchips, boardwalk, etc.), replacing rails, footings, etc. and removing
invasive vegetation or fallen trees from trails.
LITTER PICK-UP
Some heavy lifting is involved (i.e., appliances, furniture, tires, etc.) as is risk from high traffic areas, ditches, sharps
& RECYCLING
Such as syringes, glass, metal, etc., waste products and snakes.
MECHANICAL
Work class is unique in that the individual possesses and uses the necessary skills to perform limited maintenance
on mechanical equipment routinely used in the performance of regular duties.
SAND BAGGING
Workers fill burlap or nylon bags with 40-50 pounds of sand and place them as barriers to prevent further erosion on
stream banks and to protect homes and structures from flood events.
CLEANING RETENTION
Crews use hand tools, such as rakes and nets, to remove unwanted vegetation and litter from ponds. Crews also
PONDS
dispose of the debris collected.
LEVEL ONE PROJECTS
SANDING / SALTING
Crews spread sand and salt on slick/icy surfaces to prevent accidents. Lifting and carrying heavy bags, drums and
containers is required. Shovels are used in large areas. Workers fill burlap or nylon bags with 40-50 pounds of sand i
and place them as barriers to prevent further erosion on stream banks and to protect homes and structures from
flood events.
LANDSCAPING
Primarily for re -forestation. Developing or enhancing an area by adding trees, plants or other features. Use of hand
and power tools is required. Worker knowledge, skill and experience are critical.
TRUCKS — LOAD/UNLOAD
Workers unload various trucks and pallets. Work requires the ability to work long hours on their feet while repetitively
loading and unloading boxes, bags, or misc. items. Work requires little specific training or direction.
GENERAL LABOR
Miscellaneous labor not otherwise categorized. Most tasks require no formal training.
Washington State Attachment B Page 2 of 2
Department of Corrections
ATTACHMENT C
Washington State Department of Corrections
Statewide Safety Program
COMMUNITY RESTITUTION PROHIBITED WORK
May NOT Be Performed By Community Restitution Workers
1. Work requiring the use of a respirator, the exception is a dust mask. Respirators are
anything regulated by the National Institute for Occupational Safety and Health
(NIOSH), such as an N-95 particle mask, half mask, full face, PAPR or a supplied air
respirator.
2. Work involving explosives, including fireworks.
3. Work where there is exposure to X-ray or radioactive isotopes.
4. Work with electrical wires, performing electrical work, working with energized lines, or
within 10 feet of an exposed and energized line.
5. Demolition or any other work where there is known or suspected asbestos -containing
material, i.e. boats, ships and buildings constructed before 1980.
6. Demolition of boats and ships or any structure which would require work in confined
spaces.
7. Work on structures on or over water such as docks and piers.
8. Work requiring the use of hazardous chemicals, i.e. pesticides and herbicides, unless
the local government -non-profit agency has certified to the Department that it is in
compliance with WAC 296-307-13025 and WAC 296-800-170.
9. Work at any location where there is known or suspected hazardous materials or
environmental hazards, i.e. PCBs.
10. Work handling or picking up needles, razor blades, or other sharp objects.
11. Logging or timbering activities, with the exception of Department of Natural Resources
work crews and supervised wood cutting/splitting.
12. Work in homeless encampments and/or tent cities, whether populated or not.
13. Workers will not be utilized for crowd control and moving individuals' personal
properties.
Washington State Attachment C Page 1 of 1
Department of Corrections
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level: 2
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason.gerwen@cilyoffederalway.com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email dveqK@docl.wa.gov
DOC Matrix _ Work Project Title: Illegal Dumpsite Cleanup Project Date(s): 12/01/2021-11/30/2022
Project Location(s): Various locations Within the City of Federal Way Contract: K12614
ELEMENTS/ACTIVITIES
Illegal dumpsite cleanups
I
SPECIFIC TASKS I HAZARDS I CONTROLS
Picking up litter,
furniture and other
items illegally dumped
in areas around the
Weather— rain/snow
Wear appropriate
clothing and footwear
to keep warm and dry
Wear appropriate
clothing, drink plenty
of fluids, take breaks
in the shade if possible
Wear appropriate
clothing, maintain
distance from others
when possible, do not
touch items or people
without proper PPE,
do not work while sick
-Be aware of what you
are touching, do not
reach into areas you
cannot see
PPE
Rain Coat, boots,
hard hats, gloves
Hard hats
Gloves, surgical
masks or other
face coverings,
boots
Puncture resistant
gloves, litter
pickers
PROVIDER of PPE
& TRAIN TO USE
DOC
DOC
DOC
DOC
Be aware of Dust mask, eye DOC
surroundings, have protection
windows open and
allow air -flow to
Washington State K12614 Page 1 of 3
Department of Corrections Attachment D
reduce dust
accumulation in the air
Be aware of
Eye protection
Debris in Eyes ! surroundings, work
slowly
_
Slipping/tripping/falling
Watch where you are
Hard -soled boots
walking, step carefully
or rubber boots
on or around items
suitable for
outdoor work.
Traffic
noise
Ear plugs
i
DOC
DOC
Bug bites Wear long pants and Bug repellant DOC
long sleeved shirts
Lifting items into trucks/vans Placing items into Lifting injury Learn and use proper DOC
Crew Deployment
Travel in vehicles
trucks or vans for.
disposal
Entering and Exiting
Vehicles
Riding to and from
worksite locations
Struck by moving
vehicle
Vehicle accident
lifting techniques,
obtain assistance from
other crew members
for heavy or large
items
Exit vehicle on the side Wear high visibility DOC
of the vehicle away ANSI Class 2 or 3
from the road safety vests and
hard hats
Work facing oncoming
traffic
Never enter traffic to
retrieve equipment
Park vehicle -as far off
the roadway as is safe
Wear high visibility
clothing, use traffic
cones and emergency
flashers on vehicles
Wear seatbelts and
remain seated in
moving vehicles at all
times, do not lean out
or stick hands out of
open windows
DOC
_ I
DOC
I DOC
DOC
Seatbelts E DOC
Washington State K12614 Page 2 of 3
Department of Corrections Attachment D
SPECIAL EQUIPMENT THAT WORKERS WILL USE FOR THIS PROJECT:
TASK
HAZARDS TYPE
RISK LEVEL
EQUIPMENT
PROVIDER of SPECIAL EQUIP.
& TRAIN TO USE
DOC
_
Picking up piles of garbage
Scrapes/cuts from hidden
Mod
_
Shovels, Rakes
sharp objects
Picking up small items
Scrapes/cuts from sharp
Mod
Litter Pickers
DOC
objects
Scrapes/cuts from thorns
_
Mod
Clippers, Pruners
DOC
Cutting brush/blackberries
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
I f0
ature) Date
(FI(inted Name) Title
Department JSA Contact
x�e
Signature) Date
Rene Vertz — Workcrew Program Manager
(Printed Name)
Title
Instructions: Please use this form as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: "operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this point, assume
that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result from each hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity, emissions, chemicals, low
oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing in the ears
and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation, unconsciousness and even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local exhaust
ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or minimized with controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 3 of 3
Department of Corrections Attachment D
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level: 2
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason. erwen ci offederalwa .com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: jvertz ._docl wa.gov
DOC Matrix — Work Project Title: Litter Cleanup Project Date(s): 12/01/2021-11130/2022
Project Location(s): Various locations within the City of Federal Way Contract: K12614
ELEMENTS/ACTIVITIES I SPECIFIC TASKS I HAZARDS
Litter removal Picking up litter on Weather— rain/snow
the side of the road
CONTROLS
PPE
PROVIDER of PPE
& TRAIN TO USE
Wear appropriate
Rain Coat, boots, DOC
clothing and footwear
hard hats, gloves
to keep warm and dry
Wear appropriate
Hard hats
DOC
clothing, drink plenty
of fluids, take breaks
I in the shade if possible
Gloves, surgical
DOC
Wear appropriate
clothing, maintain
masks or other
distance from others
face coverings,
when possible, do not
boots
touch items or people
without proper PPE,
do not work while sick
Be aware of what you
DOC
Puncture resistant
are touching, do not
gloves, litter
reach into areas you
pickers
cannot see
Be aware of
surroundings, have
windows open and
allow air -flow to
reduce dust
accumulation in the air
Dust mask, eye
protection
DOC
Washington State K12614 Page 1 of 3
Department of Corrections Attachment D
Be aware of Eye protection
DOC
Debris in Eyes
surroundings, work
slowly
S li ppi ng/trippi ng/fa I ling
Watch where you are
Hard -soled boots
DOC
walking, step carefully
or rubber boots
on or around items
suitable for
j
Traffic noise
outdoor work.
Ear plugs
DOC
Bug bites
Wear long pants and
Bug repellant
j DOC
Lifting items into trucks/vans Placing items into Lifting injury
trucks or vans for 1
disposal
1
Crew Deployment
Entering and Exiting Struck by moving
Vehicles vehicle
Travel in vehicles Riding to and from
worksite locations
Washington State
Department of Corrections
long sleeved shirts
Learn and use proper
DOC
lifting techniques,
obtain assistance from
other crew members
for heavy or large
items
DOC
Exit vehicle on the side Wear high visibility
of the vehicle away ANSI Class 2 or 3
from the road safety vests and
hard hats
Work facing oncoming
traffic
Never enter traffic to
retrieve equipment
Park vehicle as far off
the roadway as is safe
Wear high visibility
clothing, use traffic
cones and emergency
flashers on vehicles
Vehicle accident Wear seatbelts and Seatbelts
remain seated in
moving vehicles at all
times, do not lean out
or stick hands out of
i open windows 1
K12614
Attachment D
DOC
DOC
DOC
DOC
eR,
Page 2 of 3
SPECIAL EQUIPMENT THAT WORKERS WILL USE FOR THIS PROJECT:
TASK HAZARDS TYPE RISK LEVEL I EQUIPMENT PROVIDER of SPECIAL EQUIP
& TRAIN TO USE
Picking up piles of garbage
Picking up small items
Scrapes/cuts from hidden
sharp objects
Scrapes/cuts from sharp
obiects
G •J
Mod
Shovels, Rakes
Litter Pickers
DOC
DOC
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
fIc? z
nature) Ir Date
�.t &- A�T-raG�
(Printed Name) Title
Department JSA Contact
ignature} �` ate
Rene Vertz — Workcrew Program Manager
(Printed Name) Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: "operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this point,
assume that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result from each
hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity, emissions,
chemicals, low oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing in the
ears and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation, unconsciousness and
even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local
exhaust ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or minimized with
controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 3 of 3
Department of Corrections Attachment D
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: Cily of Federal Way Parks Department DOC Matrix - Project Risk. Level: 2
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason_ erwen ci offederalwa .com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: dvertzCcDdoc1.wa_gov
DOC Matrix — Work Project Title: Town Center Litter Cleanup and Landscaping Maintenance
Project Date(s): 12/01/2021-11/3012022
Project Location(s): Various locations within the City of Federal Way Contract: K12614
ELEMENTS/ACTIVITIES 1 SPECIFIC TASKS
Weed and Brush Removal
Landscaping
Cutting and removing
brush, grass and
weeds
Lifting and moving
plants, soil and
landscaping rock
HAZARDS
Cuts from tools/small
machinery
Scrapes/Cuts from
brush and branches
Lifting injury
Planting trees, shrubs Cuts from tools/small
and other plants I machinery .
CONTROLS
Use proper techniques
for handling tools, be
aware of
surroundings, do not
touch sharp blades,
closed -toed shoes,
long pants and long-
sleeved shirts
Be aware of
surroundings, wear
long pants and long-
sleeved shirts
Learn and use proper
lifting techniques,
obtain assistance from
other crew members
for heavy or large
items
Use proper techniques
for handling tools, be
aware of
surroundings, do not
touch sharp blades,
PPE
Gloves, hard hats,
boots, equipment -
specific safety
training
Boots, gloves, hard
hats
Gloves, boots
Gloves, hard hats,
boots, equipment -
specific safety
training
PROVIDER of PPE
& TRAIN TO USE
DOC
DOC
DOC
DOC
Washington State K12614 Page 1 of 4
Department of Corrections Attachment D
—
closed -toed shoes,
long pants and long-
'
sleeved shirts
Litter removal
Picking up litter in the
Fall down stairs Be aware of
DOC
parking lots and on
surroundings and
the outdoor steps of
where you step. Step
the Town Center
carefully and hold
property
' handrails when
walking up or down
stairs
All Activities
Weather— rain/snow
Wear appropriate
Rain Coat, boots,
DOC
clothing and footwear
hard hats, gloves
to keep warm and dry
Wear appropriate
Weather - heat
Hard hats
DOC
clothing, drink plenty
of fluids, take breaks
in the shade if possible
Exposure to
Wear appropriate
Gloves, surgical
DOC
communicable
clothing, maintain
masks or other
diseases/pathogens
distance from others
face coverings,
when possible, do not
boots
touch items or people
without proper PPE,
not work while sick
--do
Be aware of what you
Puncture resistant
DOC
Hand Puncture
are touching, do not
gloves, litter
reach into areas you
pickers
cannot see
Dust mask, eye
DOC
Be aware of
surroundings, have
protection
Dust Exposure
windows open and
allow air -flow to
reduce dust
accumulation in the air
Be aware of
Eye protection
DOC
Washington State
Department of Corrections
Debris in Eyes surroundings, work '
slowly
Slipping/tripping/falling Watch where you are Hard -soled boots DOC
walking, step carefully or rubber boots
on or around items
K12614 Page 2 of 4
Attachment D
suitable for
_outdoor work.
Ear plugs
DOC
Traffic noise
Bug repellant
DOC
Bug bites
Wear long pants and
long sleeved shirts
Lifting items into trucks/vans
Placing items into
Lifting injury
Learn and use proper
DOC
trucks or vans for
lifting techniques,
disposal
obtain assistance from
other crew members
for heavy or large
items
Crew Deployment
Entering and Exiting
Struck by moving
Exit vehicle on the side
Wear high visibility
DOC
Vehicles
vehicle
of the vehicle away
ANSI Class 2 or 3
from the road
safety vests and
Work facing oncoming
hard hats
DOC
traffic
Never enter traffic to
DOC
retrieve equipment
Park vehicle as far off
DOC
the roadway as is safe
Wear high visibility
DOC
clothing, use traffic
cones and emergency
flashers on vehicles _
Travel in vehicles
Riding to and from
Vehicle accident Wear seatbelts and
Seatbelts
DOC
worksite locations
remain seated in
moving vehicles at all
times, do not lean out
or stick hands out of
open windows
SPECIAL EQUIPMENT THAT WORKERS WILL USE FOR THIS PROJECT:
TASK HAZARDS TYPE RISK LEVEL EQUIPMENT PROVIDER of SPECIAL EQUIP.
j & TRAIN TO USE
Picking up small items Scrapes/cuts from sharp Mod Litter Pickers DOC
objects
Planting trees/bushes Scrapes from branches Low Shovels, Rakes DOC
Leaf cleanup Slipping on wet leaves Low Leaf blower DOC
Washington State K12614 Page 3 of 4
Department of Corrections Attachment D
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA Contact
" 4� et��f : / d ZA Z_
sture) Date
(Printed Name) Ttle
Depa nt JSA Contact f �]
- !/
(Signature) Date
Rene Vertz — Workcrew Program Manager
(Printed Name)
Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: 'operating a table saw" would be an element and "installing a blade" and/or "ripping„ would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this
point, assume that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result
from each hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity,
emissions, chemicals, low oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how injuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing
in the ears and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation,
unconsciousness and even death.
Controls: Note how you will eliminate or.minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local
exhaust ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or
minimized with controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 4 of 4
Department of Corrections Attachment D
ATTACHMENT D
JOB SAFETY ANALYSIS (JSA) WORKSHEET
Recipient: City of Federal Way Parks Department DOC Matrix - Project Risk Level: 1, 2 and 3
Recipient JSA Contact: Jason Gerwen Phone: 253-835-6962 Email: Jason.gerwen(d)-cityoffedera lway_com
DOC JSA Contact: Rene Vertz Phone: 206-786-3273 Email: rj_vertzl�'qbdocl .wa.gov
DOC Matrix — Work Project Title: General Labor Project Date(s): 12/01/2021-11/3012022
Project Location(s): Various locations within the City of Federal Way Contract: K12614
ELEMENTS/ACTIVITIES
Weed and Brush Removal
Landscaping
SPECIFIC TASKS HAZARDS
Cutting and removing Cuts from tools/small
brush, grass and machinery
weeds
j Scrapes/Cuts from
brash and branches
Weed eating Cuts from tools/small
machinery
Lifting and moving Lifting injury
plants, soil and
landscaping rock
CONTROLS PPE PROVIDER of PPE
& TRAIN TO USE
Use proper techniques
for handling tools, be
aware of
surroundings, do not
touch sharp blades,
closed -toed shoes,
long pants and long-
sleeved shirts
Gloves, hard hats,
boots, equipment -
specific safety
training
DOC
Be aware of Boots, gloves, hard DOC
surroundings, wear hats
long pants and long-
sleeved shirts
Use proper techniques
for handling tools, be
aware of
surroundings, do not
touch sharp blades,
closed -toed shoes,
long pants and long-
sleeved shirts
Learn and use proper
liftingtechniques,
obtain assistance from
other crew members
Gloves, hard hats, DOC
boots, equipment -
specific safety
training
Gloves, boots
F DOC
Washington State K12614 Page 1 of 5
Department of Corrections Attachment D
Landscaping continued Planting trees, shrubs Cuts from tools/small
and other plants machinery
Trail Construction
Wood Chipping
Carpentry/Construction
Washington State
Department of Corrections
Cutting and removing
brush
Disposal of branches
and other wood
products with a
chipping machine
Putting together and
repairing small
structures and
furniture
Cuts from tools/small
machinery
Cuts/injuries from
machinery
Lifting injury
for heavy or large
items
Use proper techniques Gloves, hard hats, DOC
for handling tools, be boots, equipment -
aware of specific safety
surroundings, do not training
touch sharp blades,
closed -toed shoes,
long pants and long-
sleeved shirts
Use proper techniques
for ha ndiing tools, be
aware of
surroundings, do not
touch sharp blades,
closed -toed shoes,
long pants and long-
sleeved shirts,
Gloves, hard hats, DOC
boots, equipment -
specific safety
training
Use proper techniques
Gloves, hard hats,
DOC
for handling tools, be
boots, equipment -
aware of
specific safety
surroundings, do not
training
touch sharp blades,
closed -toed shoes,
long pants and long-
sleeved shirts,
Gloves, boots
Learn and use proper
DOC
lifting techniques,
obtain assistance from
other crew members
for heavy or large
items
Cuts/injuries from saws Use proper techniques
and other machinery for handling tools, be
aware of
surroundings, do not
touch sharp blades,
closed -toed shoes,
long pants and long-
sleeved shirts,
K12614
Attachment D
Gloves, hard hats, DOC
boots, equipment -
specific safety
training
Page 2 of 5
All activities
Washington State
Department of Corrections
Be aware of Dust mask, eye DOC
surroundings, have protection
windows open and
Dust/Debris Exposure allow air -flow to
to eyes and mouth reduce dust
accumulation in the
air, work slowly and
carefully
Weather— rain/snow Wear appropriate Rain Coat, boots, DOC
clothing and footwear hard hats, gloves
to keep warm and dry
Weather - heat Wear appropriate Hard hats DOC
clothing, drink plenty
of fluids, take breaks
_ in the shade if possible
Exposure to Wear appropriate Gloves, surgical DOC
communicable clothing, maintain masks or other
diseases/pathogens distance from others face coverings,
when possible, do not boots
touch items or people
without proper PPE,
do not work while sick _
Be aware of what you Puncture resistant DOC
Hand Puncture are touching, do not gloves, litter
reach into areas you pickers
cannot see
Dust mask, eye
Be aware of
surroundings, have
protection
Dust Exposure
windows open and
allow air -flow to
reduce dust
accumulation in the air
Be aware of
Eye protection
Debris in Eyes
surroundings, work
slowly
Slipping/tripping/fa[ling
Watch where you are
Hard -soled boots
walking, step carefully
or rubber boots
on or around items
suitable for
outdoor work.
Ear plugs
Traffic noise
K12614
Attachment D
DOC
DOC
DOC
DOC
Page 3 of 5
Bug bites
I
Lifting items into trucks/vans Placing items into Lifting injury
trucks or vans for
disposal
Crew Deployment Entering and Exiting Struck by moving
Vehicles I vehicle
Travel in vehicles Riding to and from I
Vehicle accident
I worksite locations
Wear long pants and
Bug repellant
DOC
long sleeved shirts
Learn and use proper
DOC
lifting techniques,
obtain assistance from
other crew members
for heavy or large
items
Exit vehicle on the side
l Wear high visibility
DOC
of the vehicle away
ANSI Class 2 or 3
from the road
safety vests and
hard hats
I
Work facing oncoming
, DOC
traffic
Never enter traffic to
_
DOC
retrieve equipment
Park vehicle as far off
DOC
the roadway as is safe
Wear high visibility
DOC
clothing, use traffic
cones and emergency
flashers on vehicles
Wear seatbelts and
Seatbelts
DOC
remain seated in
moving vehicles at all
times, do not lean out
or stick hands -out of
open windows
SPECIAL EQUIPMENT THAT WORKERS WILL USE FOR THIS PROJECT:
TASK I HAZARDS TYPE I RISK LEVEL I EQUIPMENT
Weed eating
Cuts from tools/small
machinery
Cutting and removing brush
Cuts from tools/small
machinery
Disposal of branches and
Cuts/injuries from
other wood products with a
machinery
chipping machine
Moderate I Gas or -electric weed eaters
Moderate
Moderate I
� I
l
Washington State K12614
Department of Corrections Attachment D
Clippers, pruners
Wood chipper
PROVIDER of SPECIAL EQUIP.
& TRAIN TO USE
DOC
DOC
City of Federal Way
I
Page 4 of 5
Cuttine brush/blackberries
Planting trees/bushes
Scrapes/cuts from thorns Low Clippers, Pruners DOC
Scrapes from branches Low Shovels, Rakes _ DOC
I certify that I performed a hazard assessment, using this form, of the above -named work site. This document constitutes my findings and certification
of this hazard assessment. I understand that this document facilitates compliance with the hazard assessment requirements of WAC 296-800-160.
Recipient JSA C nta
r [�
ignature) Date
(Printed Name) Title
❑apart nt JS ontact
(Signature} Date
Rene Vertz — Workcrew Program Manager
(Printed Name)
Title
Instructions: Please use this form "as is" to identify hazards, the ways to eliminate or control them, and what PPE to use to mitigate them.
Elements/Activities: Consider all Elements/Activities that are needed to accomplish the specific work project. List each one in Column One.
Tasks: In the Task column list the tasks that are necessary to accomplish each element.
Example: "operating a table saw" would be an element and "installing a blade" and/or "ripping" would each be separate tasks
Hazards: Note any condition at the project site or with the project itself that could potentially cause occupational injury, death, or disease. [At this
point, assume that workers are not wearing or otherwise using personal protective equipment. You may choose to detail injuries that could result
from each hazard.]
Examples of hazards include: working at heights, slippery surfaces, exposed moving machinery parts, fire, explosion, noise, electricity,
emissions, chemicals, low oxygen, repetitive tasks, heavy lifting, and exposure to infectious blood borne pathogens.
Examples of how iniuries could occur: work at heights = falls, broken bones, paralysis, or death; noise exposure = permanent and severe ringing
in the ears and/or hearing loss; exposure to chemicals = skin damage and blindness; and working in low oxygen areas = suffocation,
unconsciousness and even death.
Controls: Note how you will eliminate or minimize the hazard before using PPE.
Examples of controls include: Using a safer tool, equipment, or chemical, adding safeguards to machinery, using safer work practices, using local
exhaust ventilation for emissions, and enclosing noisy equipment or moving workers away from such equipment to reduce exposure levels.
Personal Protective Equipment (PPE): Detail the specific PPE that is needed to protect against each hazard that cannot be eliminated or
minimized with controls.
Distribution: ORIGINAL: DOC Work Unit Supervisor
COPIES: 1) Recipient Contact; 2) Facility or CCD Safety Officer; and 3) Attached to CMS contract record by DOC Contract Manager
Washington State K12614 Page 5 of 5
Department of Corrections Attachment D
STATEMENT OF WORK
I. SERVICES
ATTACHMENT E
a. DOC supervised individuals and other workers referred to DOC work crews by local and Federal
jurisdictions, collectively `workers' will provide community restitution services in one or more of
the categories below as directed by the City of Federal Way (`recipient').
b. Categories of work (see Attachment D - Job Safety Analysis sheets):
1) Illegal Dump Site Cleanup:
Workers will collect illegally dumped materials from locations within the City of Federal
Way, then contain and deliver them to waste disposal locations or containers designated by
the recipient. Workers will collect dumped items within three working days of notification
from the recipient unless additional specified project work limits crew availability.
2) Litter Cleanup:
Workers will clean up litter by hand, using hand tools when necessary, in the City of Federal Way.
Frequency and priority of area cleanups will be determined by the recipient in consultation with
DOC. Upon instruction bythe recipient, workers will collect bags of trash and other materials
resulting from persistent/nuisance location complaints within three business days of
notification.
3) General Labor Services:
Upon instruction by the recipient, workers will complete additional general labor services
including but not limited to: brush removal, mowing, weeding, landscaping, tree planting, trail
construction, wood chipping, carpentry/construction and other project work.
c. Workers will not touch or remove any hazardous materials or items that are too large, too heavy
or otherwise too dangerous to be safely handled by workers. DOC will notify the recipient of
the locations of all such materials so thatthe recipient can arrange for alternative means of
removal.
d. The City of Federal Way will direct all work performed under this Agreement, in accordance
with the terms and conditions of K12614.
H EQUIPMENT
a. DOC will provide and maintain the basic tools, equipment and supplies, including operating
vehicles, necessary for workers to provide the services required under this Agreement.
b. The provision of specialized tools, equipment, and supplies, for any specialized or unusual tasks
and general labor activities requested by the recipient shall be negotiated between the parties.
Washington State K12614 Page 1 of 2
Department of Corrections Attachment E
III DISPOSAL
DOC will deliver all garbage, recyclables, and yard waste to disposal containers provided by the
recipient or to the City's Recycling and Disposal Transfer Stations or other disposal location
designated by the recipient. The recipient will absorb or otherwise pay the cost for disposal of all
material collected by workers and will not charge DOC for disposal of materials under the terms of
this Agreement.
b. DOC will record the dates on which the recipient notifies DOC of locations requiring 1) removal of
illegally dumped materials; 2) removal of bags of trash and other materials from community
cleanup activities including discoverable litter; and the dates that such materials were actually
removed or the general labor activity work was completed.
IV DOCUMENTATION
a. DOC will retain all sign -in sheets and daily activity logs for all work completed per Washington
State Records Retention Policies.
b. DOC will provide a detailed activity report of all work completed for the recipient with each
monthly invoice and will provide additional necessary reports upon request.
Washington State K12614 Page 2 of 2
Department of Corrections Attachment E