Privacy Act Statement s1

FAX 874-7179 NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT

PRIVACY ACT STATEMENT

10 USC 5031

To improve equipment design, safety and warning devices, operating and maintenance procedures and training, administrative and engineering controls, and personnel protective devices to prevent or reduce to a minimum the accidental loss of Navy personnel and material. The information being requested will be used by officials and employees of the Naval Safety Center and those officials of the DOD to prevent mishaps and to promote and monitor safety and safety programs. Collective or individual mishap reports form the basis for safety advisories to the fleet, media material for safety publications, and for specific recommendations in the areas of human factors and equipment design to higher authority to prevent mishaps. The information being requested is voluntary, however, failure to provide the requested information will diminish the overall understanding of the causes of the mishap.

ADVICE TO WITNESS

I understand that:

a. I have been requested to voluntarily provide info to a board conducting an investigation.

b. I am not being requested to provide a statement under oath or affirmation.

c. Within DOD all info provided by me will be used only for safety purposes. It is further understood that the info contained in this report may be released in response to a Freedom of Information Act request or under the NAVOSH Program or Department of Labor regulations.

d. The info provided by me SHALL NOT be used:

(1) As evidence or to obtain evidence in determining misconduct or line of duty status of killed or injured personnel.

(2) As evidence to determine the responsibility of myself or other personnel from the standpoint of discipline.

(3) As evidence to asset affirmative claims on behalf of the government.

(4) As evidence before administrative boards of bodies.

(5) In any punitive or administrative action taken by the department of the Navy.

(6) As evidence to determine the liability of Government property damages caused by a mishap.

e. Attempts will be made to maintain the confidentiality of my statements.

______Witness’s Signature Date

NAVSUPPACTMIDSOUTH 5102/1 (Rev. 1-00) NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT

MISHAP QUESTIONNAIRE

Employee Command ______UIC ______

Shop/Division ______

Last Name ______First Name ______MI ______

Military/Civilian ______Shift ______SSN ______Date of Birth ______

Sex _____ Grade ______Job Title ______

Date of Mishap ______Time of Mishap ______On/Off Duty ______

Location of Mishap ______(Building/Room Number, Street/Intersection/Parking Lot – BE SPECIFIC)

Supervisor Name ______

Workplace Managers Name ______

Employee Statement (How did it happen? What was involved? What were you doing at the time?)

Nature of Injury

Medical Treatment (Yes/No) ______Location ______

Lost Days From ______To ______Total ______

Restricted Days From ______To ______Total ______

Date Returned to Work ______NAVSUPPACTMIDSOUTH 5102/1 (Rev. 1-00) NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT

Mishap Scene (Describe the scene including the location and environmental conditions)

Contributing Factors Leading to the Mishap

Describe the mishap in detail (including specific tasks and conditions)

What occurred after the mishap (including specific actions and conditions) NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT

NAVSUPPACTMIDSOUTH 5102/1 (Rev. 1-00) TO BE COMPLETED BY SAFETY OFFICE Case Number ______

Date of Death ______Claim Denied (Yes/No) ______

Mishap Class (A/B/C/D) ______Off Site Treatment Authorized (Yes/No) ______

Additional Lost Time

______

SR Report

Reportable Date (Julian) ______Mailed Date (Julian) ______

Reference Number (YYMM###) ______

Equipment (Yes/No) ______Chemical (Yes/No) ______

MSDS Number ______

Corrective Action Recommended

Follow Up Date ______

Corrective Action Verified NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT

Date Corrective Action Verified ______NAVSUPPACTMIDSOUTH 5102/1 (Rev. 1-00)