Attachment 1 -ds1663.PDF

PRIVACY ACT STATEMENT

VI. SUPERVISOR/POSHO INFORMATION

FILING INSTRUCTIONS

9. Name of Individual - Self Explanatory. Check the "TDY" box if employee was on a temporary duty assignment when the mishap occurred.

8. Detailed Description of Mishap - Describe in as much detail as possible, the who, what, where, when, why and how of the mishap. Include relevant remarks about weather, equipment or tools involved, unsafe conditions, acts and personal factors and whether other persons may have contributed to the accident. For environmental mishaps, describe the failures (equipment or personnel) that led to the release of chemicals or pollutants.

II. PERSONAL INFORMATION

b. Estimated Days Restricted Duty - The number of days when the employee could not perform any or all of his or her normal assignment during all or any part of the workday or shift, because of the injury or illness.

19. WORK-RELATED EMPLOYEE INJURIES ONLY

f. Employee's Shift Start Time - Enter as hh:mm.

e. Employee's Date of Hire - Enter the date as mm-dd-yyyy.

d. Treatment facility name and address (if off-site) - Self Explanatory

c. Name of treating physician/health care provider - Self Explanatory

a. Estimated Calendar Days Lost from work - A count of all calendar days (consecutive or not), including weekend days and holidays, after, but not including, the day of injury or illness onset, where the employee would have worked but could not because of the injury or illness.

Workers' Compensation Claim Filing - Do NOT send CA-1 or CA-2 forms to OBO/OPS/SHEM. Employees need to file claims electronically using the Department of Labor's ECOMP system. Contact HR/ER/WLD for additional information:

NOTE: The following categories of mishaps must be reported within 12 hours as per 15 FAM 964.4-1:

* Injury or occupational illness resulting in a fatality, permanent total disability or inpatient hospitalization;

* Property damage of $50,000 or more;

* Operations curtailed or shut down for more than 8 hours;

* Any environmental contamination.

* Injuries or occupational illnesses (with lost workdays), involving three or more employees;

Domestic Director, DESD (A/OPR/FMS/DESD) 2201 C Street, NW Washington, DC 20522-6011 or by Fax to 202-647-1873

Overseas Send the completed form to the Post Occupational Safety and Health Officer (POSHO) at your Post. If that's not possible, scan and email a copy to OBO/OPS/SHEM at:

1. Agency - Agency of injured individual or agency reporting damaged property.

6. Time of Mishap - Enter time as hh:mm. Check a.m. or p.m.

3. Organizational Symbol - For domestic mishaps only, provide office symbol of injured individual or office reporting damaged property.

7. Location of Mishap - Check all the appropriate boxes that apply for property type and ownership of USG facility or residence. Then briefly describe the specific location on the property (e.g., warehouse, swimming pool, cafeteria, office area, bedroom).

5. Date of Mishap - Enter the date of mishap as mm-dd-yyyy. For illnesses (e.g., cumulative trauma), enter the date of diagnosis or onset of disability, whichever is earlier.

4. Type of Mishap - Check one or more types that apply to this mishap.

For "Environmental Contamination," see NOTE.

2. Post/City, ST - Provide post name for overseas mishaps, US City and State for domestic mishaps.

11. Date of Birth - Enter date of injured individual's birth as mm-dd-yyyy.

10. Gender - Self Explanatory.

17. Nature of Injury or Illness - Indicate the type of injury (or property damage) or illness, such as 2nd degree burn, fracture, abrasion, contusion, amputation, hearing loss, irritation, cancer, liver disease, contamination, etc.

18. Body Part(s) Injured - Indicate the body parts(s) injured, such as lower arm, ankle, ribs, neck, head, eye, hearing, liver, respiratory tract, etc.

(Leave blank for property damage mishaps).

14. Fatality - Enter date of death if after date of mishap as mm-dd-yyyy.

13. Severity of Injury or Illness - Check all that apply. For "Fatal", "Permanent Disability", see NOTE. For "Lost time/Restricted Duty, enter the number of days in block 17. "Medical Attention Other than First Aid" are mishaps that do NOT result in lost time from work, but where medical treatment is administered by a physician or registered professional personnel under the orders of a physician. First Aid treatment (i.e., one-time treatment of minor scratches, cuts, burns, splinters and so forth) does not ordinarily require medical care, even if administered by a physician or registered professional.

15. Medical Attention - Inpatient hospitalization means being admitted to the hospital for at least one overnight stay resulting from the injury/illness. For "Emergency Room" medical care, check for any instances where the patient used emergency room services.

16. Cause of Mishap - Identify the event that resulted in the injury or illness (such as falling from, struck by, lifting, inhaling) and the object or source involved (such as ladder, tool, chemical). For property damage or environmental contamination, provide the event and source leading to the damage/contamination.

Signatures - The POSHO must review and sign off on the DS-1663.

22. Property Status - Check if property is government owned.

23. What Corrective Action Has Been or Will Be Implemented - Describe action(s) to be taken that will prevent the recurrence of similar mishaps in the future. Indicate whether actions have been implemented, or estimated date of when actions will be implemented.

12. Category and Job/Activity - For employees, check one personnel category and provide the injured employee's job title or a brief job description. (FS - Foreign Service, GS - General Service, FSN - Foreign Service National, EFM - Eligible Family Member, PSC - Personal Services Contractor, CON - Contractor. For Other - enter brief description (e.g., family member, local national)). Check the "Post-Managed Contractor?" box if the contractor is being managed by Post personnel, versus OBO personnel on an OBO-managed project.

20. Estimated Amount of Property Damage - Self Explanatory.

Leave blank for injury/illness mishaps.

REPORT OF MISHAP INSTRUCTIONS

AUTHORITY: The Occupational Safety and Health Act of 1970 (29 U.S.C. 657, 673); Secretary of Labor's Order No. 12-71 (36 FR 8754), 8-76 (441 FR 25059), or 9-83 (48 FT 35736) and Code of Federal Regulations, Occupational Safety and Health Administration, Labor (29 1904, 1-22).

A Report of Mishap (15 FAM 964) is required whenever a mishap occurs on Department-owned or -leased property, or during the conduct of U.S. Government business. Reporting is required when mishaps result in personal injury or illness, property damage, or environmental contamination.

PURPOSE: The principal purpose of the Report of Mishap is to inform safety and health officials of all occupational injuries, illnesses, official vehicle collisions, property damage, and environmental contamination incidents. Sufficient details must be provided to ensure appropriate corrective actions are developed and implemented to help prevent future occurrences. It is also used to ensure that supervisors are aware of their safety/health responsibilities.

ROUTINE USES: These reports are used to provide injury and illness data to the Department of Labor in the Department's Safety and Occupational Health Annual Report. This report is designed to document and measure the progress of the safety program. Mishap reports are reviewed during program assessments and to focus training/assistance efforts on the information contained therein.

DS-1663

05-2018

Instruction Page 1 of 1

For mishaps causing injury or illness to more than one individual, complete and attach a DS-1663 (with only sections 1-19 completed) for each additional individual.

I. MISHAP INFORMATION

III. INJURY/ILLNESS INFORMATION

V. CORRECTIVE ACTION

21. Type of Property - Such as building, residence, GOV, POV, personal property, security barrier, etc.

IV. PROPERTY DAMAGE INFORMATION

https://intranet.hr.state.sbu/Benefits_Compensation/Compensation/Pages/WorkersCompensationProgram.aspx mailto:SHEM-MRSAdmin@state.gov

21. Type of Property

23. Describe recommended action(s) that will prevent the recurrence of a similar mishap in the future, and whether or when these actions have been implemented.

16. Cause of Mishap

17. Nature of Injury or Illness (contusion, laceration, sprain, fracture, muscle strain, etc.)

18. Body Part(s) Injured

19. WORK-RELATED EMPLOYEE INJURIES ONLY:

a. Calendar Days Lost

c. Name of treating physician/health care provider

d. Treatment facility name and address (if off-site)

e. Employee's Date of Hire (mm-dd-yyyy)

f. Employee's Shift Start Time (hh:mm)

b. Days Restricted Duty

20. Est Amount of Property Damage 22. Property Status

USG owned

IV. PROPERTY DAMAGE INFORMATION

V. CORRECTIVE ACTION

VI. SUPERVISOR/POSHO INFORMATION

Supervisor's Signature

Supervisor's Name POSHO's Name and Title

Date (mm-dd-yyyy) POSHO's SignatureDate (mm-dd-yyyy)

9. Name of Individual (Last, First, MI.)

10. Gender (Check one) Male Female

11. Date of Birth (mm-dd-yyyy)

12. Category (Check one)

Job/Activity

FS GS FSN

EFMPSC CON Other

TDY

II. PERSONAL INFORMATION

8. Detailed Description of Mishap/Property Damage (please attach Form DS-1664 if Motor Vehicle)

4. Type of Mishap (Check all that apply)

Property Damage Environmental ContaminationIllness/Injury

1. Agency 2. Post/City, State 3. Organizational Symbol

5. Date of Mishap (mm-dd-yyyy) 6. Time of Mishap (hh:mm) p.m.

a.m.

13. Severity of Injury or Illness (Check all that apply)

Fatal Permanent Disability

Lost Time/ Restricted Duty Medical Attention

(Other than First Aid)

DS-1663

05-2018

REPORT OF MISHAP

p.m.

a.m.

7. Location of Mishap (Check all that apply)

Specific Location

a. Type:

b. Ownership:

OtherUSG Facility

Gov. Owned/Capital Lease Operating Lease

USG Residence

COMPLETE THIS FORM TO REPORT ALL MISHAPS RESULTING IN INJURIES, INCLUDING INJURIES FROM OFFICIAL VEHICLE MISHAPS, ILLNESSES, OR ENVIRONMENTAL CONTAMINATION

14. Fatal - Date of Death (if after date of mishap - mm-dd-yyyy)

15. Medical Attention Inpatient Hospitalization Emergency Room

U.S. Department of State

I. MISHAP INFORMATION

III. INJURY/ILLNESS INFORMATION

LQA

First Aid

Post-managed Contractor?