Army at War - “Be Safe” - Make it Home

Pre-Trip Risk Management Worksheet

CURSOR WILL AUTOMATICALLY APPEAR IN THE FIRST FIELD CALLED “NAME”. USE TAB KEY TO NAVIGATE TO REMAINING FIELDS AND ADD REQUIRED INFORMATION.

Step 1: Fill in Admin Information:

NAME:
ORGANIZATION:
STARTING POINT
CITY:
STATE (2 INITIALS ONLY)
DEPARTURE DATE (d-MMM-yy):
DESTINATION
CITY:
STATE:
ARRIVAL DATE(d-MMM-yy):
DEPARTURE DATE(d-MMM-yy):
DATE RETURN TO DUTY STATION (d-MMM-yy):

Step 2: Select answers to questions to determine your risk for this trip:

I will drive: / Large Car (2 pts)Midsize Car (3 pts)Pick-Up Truck (3 pts)Van (4 pts)Motorcycle (4 pts)Import (4 pts)Subcompact/Compact (5 pts) / 2345
I will wear my seat belt at all times: / Yes (0 pts)No (5 pts) / 05
I plan to have following amount of sleep before my trip: / >8 hrs (1 pt)6-8 hrs (2 pts)4-6 hrs (3 pts)2-4 hrs (4 pts)0-2 hrs (5 pts) / 12345
The roads I travel on will be: / Multi Lanes (2 pts)Two lanes (4 pts) / 24
I will take rest stops: / Trip is <2 hrs (1 pt)Every 2 hrs (2 pts)Every 3 hrs (3 pts)Every 3 to 4 hrs (4 pts)None. Trip is >2 hrs (5 pts) / 12345
I will start my trip between the hours of: / 0900-1500 (2 pts)1600-2000 (3 pts)0500-0900 (4 pts)2100-0600 (5 pts) / 2345
Will you have alcohol during this trip: / No (0 pts)Yes (5 pts) / 05
Most of my trip will take place during: / Day (1 pt)Dusk (2 pts)Dawn (4 pts)Night (5 pts) / 1245
I will check weather day prior to departure: / Yes (0 pts)No (5 pts) / 05
I will have my vehicle inspected by my supervisor prior to departure: / Yes (0 pts)No (5 pts) / 05
Have you ensured/made sure medications you are taking will not affect your driving: / Yes (0 pts)No (5 pts) / 05
Total Points

Step 3: Add up all the points and see Risk Management Matrix below:

Step 4: See table below for a Risk Evaluation of your trip:

Points / Trip Risk Evaluation / Your Risk
>44 / Extremely high-risk
30 - 43 / High-risk
16 - 30 / Moderate-risk
0 - 15 / Low-risk

Step 5: If your trip was high or extremely high-risk go back over your answers and see if you can lower your score by choosing an answer with less risk.

Step 6: Recalculate your scores from answers and this is the risk for your trip.

Step 7: Sign this worksheet inspace below and take it to your supervisor and have him or her sign it. Your supervisor’s signature indicates that you have conducted the risk management process on your trip and that you have identified the risks associated with it.

Traveler’s Signature:
Date Signed:
Name of Traveler’s Supervisor:
Supervisor’s Signature
Date Signed:

E/m completed form to your supervisor at least 7 days prior to your trip.

HAVE A SAFE TRIP

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BUCKLE YOUR SEAT BELT AT ALL TIMES

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MAKE SURE ALL OTHERS IN YOUR VEHICLE DO THE SAME

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PUT ALL CHILDREN IN AN APPROVED CHILD SAFETY SEAT

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DON’T DRIVE WHEN TIRED, AND, MOST IMPORTANTLY

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DON’T EVER DRINK AND DRIVE

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