Attachment 6 - DL1591 Supervisor Mishap Report.pdf

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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