Attachment 4 FAA Mishap Report FAA Form 3900-6 10-2003.pdf

FAA Mishap Report FAA Form 3900-6 (10/2003)

2. Incident Description

7. OSHA Recordable6. Shift5. Time of Incident (e.g. hh:mm)4. Day of Week3. Date of Incident (e.g. mm/dd/yyyy)

Yes No

11. WCIS Case No.10. Region of Incident 12. Facility Type (of incident)9. CA-2 Submitted8. CA-1 Submitted

OtherNoYes Unknown Yes UnknownNo

15. Specific Location of Incident14. General Location of Incident13. Location ID (of incident)

18. Date Management Notified of Incident (if different from date of incident)17. Mishap Category16. On Premises Yes No

II. Injury/Illness Information

19. Description of Injury/Illness

21. Anatomical Location of Injury/Illness20. Nature of Injury/Illness Codes

26. Medical Treatment by Health Care Professional 27. Fatality 28. Date of Death (e.g. mm/dd/yyyy) 29. CA-6 Submitted Yes No Yes NoYes No

30. Backfill Overtime (Estimated Dollar Cost of replacing worker) 31. Number of estimated hours or backfill overtime

Ill. Property/Vehicle Data

32. Description of Damage

33. Types of Damage Codes 34. FAA Property Damage Other Yes No

35. Non-FAA Property Damage 36. Property Damage Cost 37. Vehicle Damage 38. Vehicle Damage Cost Yes No Yes No

39. Vehicle Make 40. Vehicle Model 41. Vehicle License Number 42. State

43. Vehicle Operator Name 44. Vehicle Operator Job Series Number First MI Last

I. Incident Description

1. Incident Type

OtherFirst AidProperty Damage Near MissMotor VehicleInjury Illness

22. Type of Injury/Illness Codes Other

23. Source of Injury/Illness Codes Other

24. Total Days Lost #Ending DateBegin Date by

25. Total Restricted/Job Transfer Days byEnding DateBegin Date #

IV. Personnel Data

47. Date of Birth (e.g. mm/dd/yyyy)46. Sex45. Employee Name

Male FemaleFirst MI Last

51. Region50. Employee Routing Number ( e.g. AEE-XXX)49. Cost Center48. SSN (e.g. XXX-XX-XXXX)

54. Employee Category53. Job Series Number52. Line of Business/Staff Office

Office

61. Name of Employee's First-Line Supervisor59. Years of FAA Employment (Nearest Whole Number)

60. Years Employed in Occupation (Nearest Whole Number)

First MI Last

62. Supervisor's Telephone Number (e.g. xxx-xxx-xxxx) 63. Supervisor or designee present at time of incident

NoYes

V. Investigation Data

66. Date Report Prepared (e.g. mm/dd/yyyy)65. Investigation Report Number64. Investigation Performed

Yes No

68. Witness Phone Number (e.g. xxx-xxx-xxxx)67. Name of Witness

First MI Last

73. Investigation Result (Describe formal investigation results; include names of investigators)

74. Recommendations (Summary of investigator's recommendations)

75. Actions Taken to Prevent Recurrence (List actions taken and date completed)

VI. Submitter Information

76. Mishap Report Prepared By (if not by Supervisor) 77. Job Series Number

First MI Last

78. Job Title 79. Routing Number (e.g. AEE-XXX) 80. Telephone Number (e.g. xxx-xxx-xxxx) 81. Date of Report (e.g. mm/dd/yyyy)

55. Facility Type for OSHA 300

Other

56. Location ID for OSHA 300

57. General Job Task 58. Specific Job Task

69. City/State/Zip 70. Name of Second Witness

First LastMI

71. Second Witness Phone Number (e.g. xxx-xxx-xxxx) 72. Second Witness City/State/Zip