USMC SHORE/GROUND HRST FORMAL TRAINING/HIGH-RISK TRAINING MISHAP REPORT WITH PROPERTY DAMAGE ONLY

NOTE: If this is a Class A or B Mishap, has the WESS Class A/B notification been completed?

Type Report: 5102 Mishap - Personnel Injury or Illness Report

SCREEN 1: Mishap Data Entry – Mishap Involved

  1. Select, During Formal Training
  2. Select HRST Techniques
  3. Property Damage (US Govt. Owned) > $20K
  4. Was there injury, illness, or fatality involved in the event, Select (NO)

SCREEN 2: Event General Information

  1. Date of Mishap
  2. Local Time
  3. Locally assigned SER. #
  4. One line summary of incident (Brief Narrative)
  5. Was alcohol involved in this mishap (Yes/No/Unknown)
  6. Were drugs involved in this mishap (Yes/No/Unknown)

SCREEN 3: Mishap Type, Select, Add New Entry

a. Type of Mishap event (Select one or more from pull down list)

SCREEN 4: UIC/MCC/RUC of Reporting Activity - Enter UIC or Name and click Search

  1. UIC / Activity name
  2. Select reporting activity from search results list

SCREEN 5: Point of Contact information

  1. Last name
  2. First name
  3. Middle initial
  4. Rank/Rate/Grade
  5. Primary phone number
  6. Secondary phone number
  7. DSN prefix
  8. Email address

SCREEN 6: UIC/MCC/RUC of Point of Contact - Enter UIC or Name and click Search

  1. UIC / Activity name
  2. Select reporting activity from search results list

SCREEN 6A: USMC Safety Representative Information

  1. Is Safety Rep Military or Civilian
  2. Rank/Grade of Safety Representative
  3. Date of Last Inspection

SCREEN 6B:Type of Last Inspection

  1. General (Select Type)
  2. Specific (Select Type)

SCREEN 6C: Safety Courses Completed by USMC Safety Representative

  1. Select, add new entry
  2. Select from pull-down menu
  3. Date completed

SCREEN 7: UIC/RUC/MCC of Location where Mishap Occurred (If on a Gov’t Facility) - Enter UIC or Name and click Search

  1. UIC / Activity name

Select Activity from search results list

SCREEN 8: Mishap location

a. Did mishap occur on a government base or vessel? {Yes/No}

  1. Was the mishap influenced by environmental conditions such as wind, temperature or visibility? {Yes/No}

SCREEN 9: Formal Training- If Mishap Occurred During Formal Training

  1. Training Course Identification (Select from list)
  2. Other (Add Course, if not found in list)

SCREEN 10: Location Information

  1. County
  2. Township
  3. City
  4. State
  5. Country

SCREEN 11: Command or Activity with People, Property or Facilities involved. (Select Add New Entry and in drop down menu, Enter UIC or Name and click Search)

  1. UIC / Activity name
  2. Select Activity from search results list

SCREEN 12: Currently Deployed (Yes/No/Not Applicable)

SCREEN 13: USMC Not Deployed

  1. Component (Select)
  2. Major Command (Select)
  3. Parent (Select
  4. Unit (Select)

SCREEN 14: Unit Employment – Enter exercise or operation name (if applicable)

SCREEN 15: Specific Unit Evolution at time of mishap – Select from drop down menu

  1. General Type: (Explosive or Non-Explosive Mishap)

b. Specific Type: Select from drop down menu.

SCREEN 16: Command /Activity with People, Property or Facility Involved

  1. Select as appropriate, for multiple items repeat screens 10 – 14 as appropriate, if multiple selection no required select next.

SCREEN 17: Involved Property Damage in US Dollars

  1. Total cost of damage to US GOVT OWNED property
  2. Total cost of damage to NON-US GOVT OWNED property caused by government
  3. Number of mission days lost

SCREEN 18: Involved Property (Select, Add New Entry)

SCREEN 19: Property Information

  1. Is this property Govt. owned or leased? (YES/NO)
  2. Is this item (Select one)
  3. Name/nomenclature of involved equipment
  4. Is this property Currently Deployed? (Select one)

SCREEN 20: Specify Property Association (Select one)

SCREEN 21: Involved Property Location

  1. General Level
  2. Specific Level
  3. Fine Level
  4. Extreme Level

SCREEN 22: Property/Equipment Involved in the Mishap (Including Motor/Tactical/Recreational Vehicle Information)

  1. Item name/nomenclature of damaged equipment
  2. Description of equipment damage
  3. Year
  4. Make
  5. Model
  6. Series
  7. TAMS number
  8. EIC
  9. NSN
  10. Non-Govt. property/equipment owner
  11. Non-Govt. property/equipment user if different from owner

SCREEN 23: UIC/MCC/RUC of Activity Owning Equipment

  1. UIC / Activity name
  2. Select Activity from search results list

SCREEN 24: UIC/MCC/RUC of Activity Using Equipment

a. UIC / Activity name

b. Select Activity from search results list

SCREEN 25: USMC Not Deployed

  1. Component (Select)
  2. Major Command (Select)
  3. Parent (Select
  4. Unit (Select)

SCREEN 26: Involved people – Include all people, even if not injured.

  1. Select Add new entry

SCREEN 27: Involved Person – General information (page 1)

  1. Last name
  2. First Name
  3. Middle Initial
  4. SSN
  5. Date of birth or age

SCREEN 28: Specify person association - Select either

  1. Default Activity name involved or

b. Shore activity name not yet entered

SCREEN 29: Location of involved person during mishap

  1. Type of location (Shore/Ground/Shipyard)
  2. General location (Government/Non-Government)
  3. Specific location (select from pull down list)
  4. Detailed location (select from pull down list)

SCREEN 30: Involved Person – General information (Page 3)

  1. Injury/Illness severity (Select from pull down menu)
  2. DOD affiliation (Military/DOD Civilian/DOD Civilian TAD/Foreign National/None of the above)
  3. Duty Status (On duty/Off Duty/N/A)
  4. Was the person deployed at the time of the MISHAP? Yes/No or N/A

SCREEN 31: Involved Person – General Information(Page 4)

  1. Gender M/F
  2. Height (Inches)
  3. Weight (Lbs)
  4. Marital Status: (Req’d for Military Only)

e. Number of Dependents (Req’d for Military Only)

SCREEN 32: Personnel Section

  1. Branch of Service (Select from drop down list)
  2. Service Status (Select from drop down list)

c. Enlisted or Officer ?

SCREEN 33: Personnel Section (Cont’d)

  1. Primary NEC (MOS)
  2. Special Category (Select from menu)
  3. Pay Grade (Select from drop-down menu)

SCREEN 34: UIC/MCC/RUC of Involved Person (Enter UIC or Name and click Search or Select Default Activity)

  1. UIC / Activity Name
  2. Select activity name from search results list

SCREEN 35: USMC Not Deployed

  1. Component (Select)
  2. Major Command (Select)
  3. Parent (Select
  4. Unit (Select)

SCREEN 36: Involved Person - First Line Supervisor

  1. Last Name
  2. First Name
  3. Middle Initial
  4. Supervisor’s Badge Number
  5. Involved Person Badge Number
  6. Rank/Rate/Grade
  7. Shift individual was working (Select one)

SCREEN 37: Involved Person - Second - Line Supervisor

  1. Last Name
  2. First Name
  3. Middle Initial
  4. Badge Number
  5. Rank/Rate/Grade

SCREEN 38: Involved Person – Specific Activity

  1. Job/Skill/Activity at Time of Mishap (Select from drop down menu)
  2. Describe Specific Activity involved (Brief narrative text description)
  3. Number of Years/Months/Days of Experience at job or activity.
  4. Select Applicable Designations / Qualifications / Licenses / Certifications, if any.

SCREEN 39: Licenses/Qualifications/Certifications/Designations Held for the Specific Activity/Skill/Job Involved. (If applicable)

  1. Type of Activity (Select from menu)
  2. Specific Activity (Select from menu)
  3. License Held (Select from menu)

SCREEN 40: Involved Person – Licenses

  1. Are there restrictions? (Yes/No or N/A)
  2. Has license been revoked or lapsed? (Yes/No)
  3. Remarks on License Status – Brief text remarks
  4. Expiration Date (If applicable)

SCREEN 41: Involved Person - Mishap Related Courses (If applicable, Select Add New

Entry)

  1. Course involved person has attended pertaining to job/skill/activity person was performing at time of mishap. (Select from list)
  2. Date completed.

SCREEN 42: Personal Protective Equipment/Safety Devices – Select from list all that were a factor in the mishap, whether used or not used

Example: Select Seat Belts (Safety Lines and Belts)

SCREEN 43: Personal Protective Equipment/Safety Devices – Safety Lines/Belts.

  1. Select PPE/Safety Device from drop down menu

SCREEN 44: Protective Equipment

  1. Provide amplifying info about selected equipment – Brief description.
  2. Was PPE / Safety device required for task? (Yes/No)
  3. Was PPE / Safety device worn or used? (Yes/No)
  4. If used, was PPE used properly? (Yes/No) If not used, select No.
  5. If used, did PPE function properly? (Yes/No) If not used, select No.

SCREEN 45: Select Activity the person was performing (Select One)

Parachuting / HRST / Diving or Motor/Tactical/Recreational Vehicle

SCREEN 46: Select Specific Area of Involved Person (Select HRST person)

SCREEN 47: HRST Techniques

  1. Type of event (Select from menu)
  2. If Other
  3. Were ropers inserted into or extracted from water? (YES/NO)

SCREEN 48: Directives Associated with Rigging (Select Add New Entry)

SCREEN 49:HRST Techniques

  1. Aircraft / tower properly rigged IAW (list directive)
  2. Rigged correctly (YES/NO)

SCREEN 50: HRST Techniques

  1. LZ elevation (feet MSL)
  2. Water depth
  3. Intended height of ascent or descent (feet)
  4. Are tower points certified?
  5. Date tower points certified
  6. Was a brief conducted with all participants involved in the operation?
  7. Date brief given
  8. Time brief given
  9. Safety insert officer present (Select one)
  10. Weight of equipment worn, including combat pack (lbs)

SCREEN 51: Equipment Used During Mishap(Select, Add new entry)

SCREEN 52: List All Equipment Worn/Carried/Used During Event

  1. Piece of equipment (Select from menu)
  2. Name (nomenclature)
  3. Name of manufacturer
  4. Date of manufacture
  5. Date placed in service
  6. Date of last inspection
  7. Part number
  8. Lot number
  9. Length of rope or ladder (ft)

SCREEN 53: Involved People - Include all people in any way involved in the mishap, injured or not. (Select personnel, Add new entry, or next)This Screen ???

SCREEN 54: Property Cause Codes

  1. Select the piece of equipment to add cause codes to
  2. Select, Add cause codes to choice

SCREEN 55: Cause Codes - Select One or More Mishap Causes Applicable to the Equipment (Select, Add new entry)

SCREEN 56: Involved Equipment - Cause Code

  1. General
  2. Specific

SCREEN 57: Cause Code Narrative

  1. Cause code explanation

SCREEN 58: Personnel Cause Code

  1. Select personnel to add cause codes
  2. Select, add cause codes to selected choice

SCREEN 59: Cause Codes (Select one or more Cause Codes applicable to the Person if any)

  1. Select add new entry

SCREEN 60: Involved Person - Cause Code

a. General (select from pull down list, e.g. personnel/human factors)

  1. Specific (select from pull down list, e.g. failed to follow requirement or procedure)

SCREEN 61: Cause Code Narrative

a. Cause code explanation

SCREEN 62: Event Narrative/Lessons Learned/ Recommendations

a. Enter narrative text describing the event and any lessons learned or recommendations to prevent recurrence.