<p> FAX 874-7179 NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT</p><p>PRIVACY ACT STATEMENT</p><p>10 USC 5031</p><p>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.</p><p>ADVICE TO WITNESS</p><p>I understand that:</p><p> a. I have been requested to voluntarily provide info to a board conducting an investigation.</p><p> b. I am not being requested to provide a statement under oath or affirmation.</p><p> 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.</p><p> d. The info provided by me SHALL NOT be used:</p><p>(1) As evidence or to obtain evidence in determining misconduct or line of duty status of killed or injured personnel.</p><p>(2) As evidence to determine the responsibility of myself or other personnel from the standpoint of discipline.</p><p>(3) As evidence to asset affirmative claims on behalf of the government.</p><p>(4) As evidence before administrative boards of bodies.</p><p>(5) In any punitive or administrative action taken by the department of the Navy.</p><p>(6) As evidence to determine the liability of Government property damages caused by a mishap.</p><p> e. Attempts will be made to maintain the confidentiality of my statements.</p><p>______Witness’s Signature Date</p><p>NAVSUPPACTMIDSOUTH 5102/1 (Rev. 1-00) NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT</p><p>MISHAP QUESTIONNAIRE</p><p>Employee Command ______UIC ______</p><p>Shop/Division ______</p><p>Last Name ______First Name ______MI ______</p><p>Military/Civilian ______Shift ______SSN ______Date of Birth ______</p><p>Sex _____ Grade ______Job Title ______</p><p>Date of Mishap ______Time of Mishap ______On/Off Duty ______</p><p>Location of Mishap ______(Building/Room Number, Street/Intersection/Parking Lot – BE SPECIFIC)</p><p>Supervisor Name ______</p><p>Workplace Managers Name ______</p><p>Employee Statement (How did it happen? What was involved? What were you doing at the time?)</p><p>Nature of Injury</p><p>Medical Treatment (Yes/No) ______Location ______</p><p>Lost Days From ______To ______Total ______</p><p>Restricted Days From ______To ______Total ______</p><p>Date Returned to Work ______NAVSUPPACTMIDSOUTH 5102/1 (Rev. 1-00) NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT</p><p>Mishap Scene (Describe the scene including the location and environmental conditions)</p><p>Contributing Factors Leading to the Mishap</p><p>Describe the mishap in detail (including specific tasks and conditions)</p><p>What occurred after the mishap (including specific actions and conditions) NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT</p><p>NAVSUPPACTMIDSOUTH 5102/1 (Rev. 1-00) TO BE COMPLETED BY SAFETY OFFICE Case Number ______</p><p>Date of Death ______Claim Denied (Yes/No) ______</p><p>Mishap Class (A/B/C/D) ______Off Site Treatment Authorized (Yes/No) ______</p><p>Additional Lost Time</p><p>______</p><p>______</p><p>______</p><p>SR Report</p><p>Reportable Date (Julian) ______Mailed Date (Julian) ______</p><p>Reference Number (YYMM###) ______</p><p>Equipment (Yes/No) ______Chemical (Yes/No) ______</p><p>MSDS Number ______</p><p>Corrective Action Recommended</p><p>Follow Up Date ______</p><p>Corrective Action Verified NAVSUPPACTMIDSOUTHINST 5102.1A PAGE OF 4 NON-VEHICULAR ACCIDENT REPORT</p><p>Date Corrective Action Verified ______NAVSUPPACTMIDSOUTH 5102/1 (Rev. 1-00)</p>