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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