Attach 8 - DL1591 Supervisor Mishap Report.pdf
PDF 34 KB Posted
- Attached to
- DDAA Vertical Lift Module Preventative/Corrective Maintenance Federal contract opportunity
- Solicitation number
- SP330025Q0080
- Issued by
- Defense Logistics Agency Distribution
About this file
This is DLA Form 1591, a Supervisory Mishap Report template used for reporting workplace accidents and incidents at Defense Logistics Agency facilities. The form is prescribed by the DLA OSHA Program and is designated For Official Use Only (FOUO).
The form includes sections for documenting incident details, injury information, property damage, and required reviews/signatures. Key sections cover incident type classification, location specifics, training factors, PPE usage, chemical involvement, injured person information, treatment details, and property damage assessment. The form also contains fields for supervisory review, safety and health review, and management review signatures. This appears to be a blank template form rather than a completed incident report.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Attach 13 - DOL Wage Determination 2015-4587 dtd 23Dec2024.pdf | ||
| Amendment 0001 SF30 SP330025Q0080.pdf | ||
| Attach 6 - DD2875 System Authorization Access Request.pdf | ||
| Attach 2 - PWS - VLM - DDAA.pdf | ||
| Attach 12 - QASP DLA Distributiuon Anniston.docx | DOCX document | |
| Attach 7 - DL0584 Visitor Register Form.pdf | ||
| Attach 3 - DDAA VLM Equipment List.xlsx | XLSX spreadsheet | |
| Attach 1 - Schedule of Services - DDAA Modula VLM.xlsx | XLSX spreadsheet | |
| Attach 12 - QASP - CAP- VLMs Mntc.pdf | ||
| Attach 10 - TE 1.1 Contractor Personnel Sec.pdf | ||
| Attach 4 - PM - LEVELS OF MAINTENANCE.pdf | ||
| Attach 11 - TE_1.2_CAC_Procedures.pdf | ||
| Attach 9 - DL1818 Visitor Notification Form.pdf | ||
| Attach 5 - DDAA Bldg. 362 VLM Storage System Project Drawings.pdf | ||
| CSS SP3300-25-Q-0080.pdf |
Show all 15
On GovTribe
Work with this file on GovTribe
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Please wait...
If this message is not eventually replaced by the proper contents of the document, your PDF viewer may not be able to display this type of document.
You can upgrade to the latest version of Adobe Reader for Windows®, Mac, or Linux® by visiting http://www.adobe.com/go/reader_download.
For more assistance with Adobe Reader visit http://www.adobe.com/go/acrreader.
Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.
PDF (DLA)
DLA FORM 1591, JUN 2014
SUPERVISORY MISHAP REPORT
Page of For Official Use Only For Official Use Only Prescribed by: DLA OSHA Prg Sponsor: DS
PRIVACY ACT STATEMENT
5 U.S.C. 41 4101- 4118, the Government Employees Training Act of 1958; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5042, Commandant of the Marine Corps; E.O. 12196, Occupational Safety and Health Programs for Federal Employees; DoD Instruction 6055.7, Accident Investigation, Reporting, and Record Keeping; and E.O. 9397 (SSN), as amended.
Information is collected to comply with regulatory reporting requirements. Details about the accident site will be used to identify and correct known or potential hazards and to formulate improved accident prevention programs. The data, with all personal identifiers removed, may be used to prepare statistical reports.
Information may disclosed to the Department of Labor and Occupational Safety and Health Administration (OSHA) to comply with requirements of 29 CFR part 1960. The DoD “Blanket Routine Uses” also apply to this system of records.Voluntary; however, failure to provide the requested data may result in our inability to comply with reporting requirements or to identify and correct workplace hazards.Rules for collecting, using, retaining and safeguarding this information are contained in the Department of the Navy system of records notice NM05100-5, entitled “Enterprise Safety Applications Management System.”
Authority:
Purpose:
Routine Uses:
Disclosure:
Rules of Use:
INCIDENT
3. DID THE INCIDENT OCCUR ON BASE?
7. WAS A GOVERNMENT MOTOR VEHICLE INVOLVED?
10. INCIDENT TYPE (Check all that apply)
11. WAS TRAINING OR LACK OF
TRAINING A FACTOR?
12. WAS PPE USE OR LACK OF
USE A FACTOR?
13. WERE CHEMICAL(S) A FACTOR?
16. ADDITIONAL INCIDENT COMMENTS TO ASSIST THE SAFETY OFFICE INVESTIGATION
Comment Date Added Added By
17. ADDITIONAL SUPERVISORS (Add additional supervisors who need access to this incident. The submitting supervisor and/or employee's supervisor already have access. NOTE: Each supervisor added will receive an email notification and be able to view this incident.
Name Email Address
18. INDIVIDUAL FILING INCIDENT
INJURY
19. INJURED PERSON INFORMATION
I. SEX
22. PAY STATUS
24. WAS PERSON TREATED AT ER?
26. EXPERIENCE WITH TASK
PROPERTY DAMAGE
40. INVOLVED PERSON INFORMATION
I. SEX
REVIEW AND SIGNATURES
SUPERVISORY REVIEW
SAFETY AND HEALTH REVIEW
MANAGEMENT REVIEW
9.0.0.2.20100902.2.720808 http://www.dla.mil/officialforms/files1/dl1591.pdf
PII, FOUO
DL1591
installation support, safety Supervisor Mishap Report June 2014
| CurrentPage: |
| PageCount: |
| incidentDate: |
| incidentTime: |
| yes: 0 |
| yes: 0 |
| yes: 0 |
| yes: 0 |
| yes: 0 |
| yes: 0 |
| yes: 0 |
| yes: 0 |
| yes: 0 |
| yes: 0 |
| no: 0 |
| no: 0 |
| no: 0 |
| no: 0 |
| no: 0 |
| no: 0 |
| installationLocation: |
| narrative: |
| locationSpecific: |
| numPeople: |
| jobProjOrderID: |
| assaultViolent: 0 |
| nonRecBoating: 0 |
| airDropCargo: 0 |
| handlingCargo: 0 |
| afloatCollision: 0 |
| craftCollision: 0 |
| nonEnCombat: 0 |
| contactObjEquip: 0 |
| deck: 0 |
| driving: 0 |
| electShockBurn: 0 |
| equipInstRepair: 0 |
| nonIndEquipOper: 0 |
| nonOrdExplosion: 0 |
| envExposure: 0 |
| fallSlipTrip: 0 |
| fires: 0 |
| floodingAfloat: 0 |
| groundingAfloat: 0 |
| hazMat: 0 |
| heavyWeather: 0 |
| HRST: 0 |
| industrial: 0 |
| insertExtraction: 0 |
| lostMissingSea: 0 |
| manOverSide: 0 |
| manOverboard: 0 |
| matHandlingEquip: 0 |
| occupNonIndust: 0 |
| ordRelatedNonExpl: 0 |
| ordRelatedExp: 0 |
| other: 0 |
| parachuting: 0 |
| PRTetc: 0 |
| recreation: 0 |
| recEvent: 0 |
| shipControlNav: 0 |
| training: 0 |
| vehicle: 0 |
| weapon: 0 |
| how: |
| TextBox: |
| otherFactors: |
| actionsTaken: |
| Click to add/more/remove comments: |
| comment: |
| addDate: |
| addBy: |
| supName: |
| supEmail: |
| name: |
| commandOrg: |
| dept: |
| installation: |
| phone: |
| lastName: |
| firstName: |
| midName: |
| suffix: |
| dob: |
| serviceStatus: |
| gradeRank: |
| rateSeries: |
| supervisorDuringIncident: |
| currentSupervisor: |
| jobTitleHR: |
| supervisorNotifiedDate: |
| onDuty: 0 |
| offDuty: 0 |
| treatedBy: |
| returnDate: |
| numYears: |
| numMonths: |
| numDays: |
| drugAlcohol: |
| occurDuring: |
| bodyParts: |
| activity: |
| propDesc: |
| propType: |
| propID: |
| extentDam: |
| propOwner: |
| estCost: |
| daysLost: |
| SignatureField1: |
File details come from the government source that posted it. Updated .