USMC SHORE/GROUND 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 And Property Damage

SCREEN 1: Mishap Data Entry – Mishap Involved

  1. Select, During Formal Training
  2. Select, Property Damage (US Govt. Owned) > $20K
  3. 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 – 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: 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 11: Currently Deployed (Yes/No/Not Applicable)

SCREEN 12: USMC Not Deployed

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

SCREEN 13: Unit Employment – Enter exercise or operation name (if applicable)

SCREEN 14: 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 15: 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 16: 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 17: Involved property (Select, Add new entry)

  1. Is this property Govt. owned or leased?
  2. Is this item (Select from list)
  3. Name/nomenclature of involved equipment
  4. Is this property Currently Deployed?

SCREEN 18: Specific Property Association (Select one)

SCREEN 19: Involved Property Location

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

SCREEN 20: Property/Equipment Involved in the Mishap (Including Motor/Tactical/Recreational Vehicle Information)

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

SCREEN 21: UIC/MCC/RUC of Activity Owning Equipment

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

SCREEN 22: UIC/MCC/RUC of Activity Using Equipment

a. UIC / Activity Name

  1. Select activity name from search results list

SCREEN 23: USMC Not Deployed

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

SCREEN 24: Involved people – Include all people, even if not injured.

  1. Select Add new entry

SCREEN 25: Involved Person – General information (page 1)

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

SCREEN 26: Specify person association - Select either

  1. Default Activity name involved or

b. Shore activity name not yet entered

SCREEN 27: 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 28: 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 29: Involved Person – General Information(Page 4)

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

SCREEN 30: Personnel Section

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

c. Enlisted or Officer ?

SCREEN 31: Personnel Section (Cont’d)

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

SCREEN 32: 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 33: USMC Not Deployed

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

SCREEN 34: 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 35: Involved Person - Second - Line Supervisor

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

SCREEN 36: 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. (If no selection in made skip screens 37 and 38)

SCREEN 37: Licenses Held for the Specific Activity/Skill/Job Involved.

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

SCREEN 38: 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 39: 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 40: 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 41: Personal Protective Equipment/Safety Devices – Safety Lines/Belts.

  1. Select PPE/Safety Device from drop down menu

SCREEN 42: 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 43: Select Activity the person was performing (Not applicable in this mishap)

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

SCREEN 44: Property Cause Codes

  1. Select the piece of equipment to add cause codes to

SCREEN 45: Cause Codes - Select One or More Mishap Causes Applicable to the Equipment, (Select Add, new entry)

SCREEN 46: Involved Equipment - Cause Code

  1. General (Select from drop-down menu)
  2. Specific (Select from drop-down menu)

SCREEN 47: Cause Code Narrative, Cause code explanation

SCREEN 48: Personnel Cause Code

  1. Select personnel to add cause codes

SCREEN 49: Cause Codes – Select one or more Cause Codes applicable to the Person if any (Select, Add new entry)

  1. General (select from pull down list, e.g. personnel/human factors)
  2. Specific (select from pull down list, e.g. failed to follow requirement or procedure)

SCREEN 50: Cause Code Explanation - Brief Narrative (Fill in, if needed)

SCREEN 51: Event Narrative/Lessons Learned/ Recommendations

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