PROPERTY DAMAGE With INJURY

SCREEN 1: Mishap Involved

  1. Select ship/sub/small craft or shore/ground/shipyard
  2. Select Property damage non-US Government or US Government
  3. Was there injury, illness, or fatality involved in the event (NO)

SCREEN 2: Event General Information

  1. Date of Mishap
  2. Local Time
  3. Locally assigned SER. #
  4. One line summary of mishap
  5. Was alcohol involved in this mishap
  6. Were drugs involved in this mishap

SCREEN 3: Type of Mishap event(select from pull down list)

SCREEN 4: UIC of reporting activity

  1. UIC
  2. Activity name

SCREEN 5: Point of Contact information

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

SCREEN 6: UIC of Point of Contact

  1. UIC
  2. Activity name

SCREEN 7: Mishap location

a. Did mishap occur on a government base or vessel yes or no/unknown

b. Was the mishap influenced by environmental conditions such as wind, temperature or visibility. yes or no/unknown

SCREEN 8: Ship/Sub/Small craft information

  1. Latitude
  2. Longitude
  3. Restricted waters yes or no/unknown
  4. Sea state
  5. Direction

SCREEN 9: General location of ship

  1. Body of water

or

  1. Port

SCREEN10: Command or activity involved

SCREEN11: UIC of command or activity involved

  1. UIC
  2. Activity name

SCREEN 12: Ship/Sub/Small craft Location

  1. Vessel type (Ship/Sub/Small craft)
  2. Vessel status (Anchored, Moored, Dry-docked, other, shipyard drydocked, shipyard moored, submerged, or underway)
  3. Small or service craft (if applicable)
  4. Is this activity currently deployed yes or no/unknown

SCREEN 13: Employment

  1. Exercise or operation name
  2. Date left port (if underway)
  3. Date left home port (if deployed)
  4. Landing craft payload type cargo
  5. Landing craft payload weight (In tons)

SCREEN 14: Specific Unit evolution at Time of mishap

  1. General Type (explosive or non-explosive)
  2. Specific Type (select from pull down list)

SCREEN 15: 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 16: Involved property

  1. Add new entry

SCREEN 17: Property Information

a. Is this property Govt. owned or leased? Yes or no

  1. Is this item (airdropped cargo/Ordnance/Other)
  2. Name/nomenclature of involved equipment
  3. Is equipment currently deployed Yes or no or N/A

SCREEN 18: Specify Property Association

  1. Shore activity name not yet entered
  2. Ship activity 1 name not yet entered
  3. Ship activity 2 name not yet entered
  4. Activity not yet entered

SCREEN 19: Involved property location

  1. General level (Aviation/Ship/Sub/Small Craft)
  2. Specific level (Government/Non-Government)
  3. Fine level (select from pull down list)
  4. Extreme level (select from pull down list)
  5. BLDG#/Room/Shop/Compartment number

SCREEN 20: Property/Equipment involved in the mishap

  1. Item name/nomenclature of damaged equipment (23 characters)
  2. Description of equipment damage (70 characters)
  3. Year
  4. Make
  5. Model
  6. Series
  7. TAMS number
  8. Serial number
  9. EIC
  10. NSN
  11. Non-government property/equipment owner
  12. Non-government property/equipment operator

SCREEN 21: Involved people- even if not injured

  1. Add new entry

SCREEN 22: Involved Person – General information

a. Name:

b. Social Security Number:

c. Date of Birth:

d. Age:

SCREEN 23: Specify person association

  1. Shore activity name not yet entered
  2. Ship activity 1 name not yet entered
  3. Ship activity 2 name not yet entered
  4. Activity not yet entered

SCREEN 24: Location of involved person during mishap

  1. Type of location (Aviation/Ship/Sub/Small Craft)
  2. General location (Government/Non-Government)
  3. Specific location (select from pull down list)
  4. Detailed location (select from pull down list)
  5. BLDG#/Room/Shop/Compartment number

SCREEN 25: Involved Person – General information

  1. Injury/Illness severity (No injury or illness)
  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 or no or N/A

SCREEN 26: Involved Person – General information

  1. Sex:
  2. Height: in.
  3. Weight: lbs.
  4. Marital Status:

SCREEN 27: Personnel Section

  1. Branch of Service
  2. Service Status
  3. Enlisted or Officer

SCREEN 28: Personnel Section

  1. Primary NEC:
  2. Rating:
  3. Pay Grade

SCREEN 29: Involved Person – Specific Activity

  1. Job Skill:
  2. Specific Activity:
  3. Experience:

SCREEN 30: Courses Attended:

SCREEN 31: Personal Protective Equipment:

  1. Select all that apply:

SCREEN 32: Equipment Category:

SCREEN 33: Select Activity the Person was performing:

SCREEN 34: Injury / Occupational Illness Information

  1. Injury resulted in?
  2. Chemical Involved?
  3. Were Sharps Involved?
  4. Was Person Hospitalized?
  5. Was heat or Cold a Factor?

SCREEN 35: Lost Work Time

  1. Add New Entry

SCREEN 36: Injured Person Information

  1. Person Permanently Transferred?

SCREEN 37: Injury / Occupational Illness Information

  1. Source of Injury:
  2. OSHA Code:

SCREEN 38: Source of Injury or Occupational Illness:

  1. General Type:
  2. Specific Type:

SCREEN 39: Event or Exposure

  1. General Type:
  2. Specific Type:
  3. Fine:
  4. Specific:

SCREEN 40: Injured Body Parts

  1. Add New Entry
  2. Level One
  3. Level two

SCREEN 41: Primary Injury

  1. Is this the primary injured body part? Yes or No

SCREEN 42: Nature of Injury

  1. General Level:
  2. Specific Level:
  3. Detailed Level:

SCREEN 43: Injury / Occupational Illness Information

  1. Initial Medical Treatment

SCREEN 44: Property Cause Code

  1. Select equipment

SCREEN 45: Involved Equipment- Cause code

  1. General (select from pull down list)
  2. Specific (select from pull down list)

SCREEN 46: Cause Code Narrative (Fill in)

SCREEN 47: Personnel Cause Code

  1. Select personnel

SCREEN 48: Involved Personnel- Cause Code

  1. General (select from pull down list)
  2. Specific (select from pull down list)

SCREEN 49: Cause Code Narrative (Fill in)

SCREEN 50: Event Narrative/Lessons Learned/ Recommendations