Attachment 8 NAVFAC Mishap Notice Form.pdf
PDF 1 MB Posted
- Solicitation number
- N4008524B2505
About this file
This is a NAVFAC Initial Mishap Notification form used to report incidents occurring at Naval Facilities Engineering Command sites. The form includes fields for documenting essential incident details including: the activity location, type of work being performed, date/time of mishap, description of incident and injuries, initial corrective actions, property damage assessment, safety investigator assignment, supervisor information, and anticipated Mishap Review Board date. The form requires indicating whether the involved party is Navy Civilian, Contractor, or Military personnel.
This form appears as Attachment 8 in solicitation N4008524B2505 for an IDIQ Miscellaneous Paving Maintenance and Repair Contract at NSA Mechanicsburg/NSA Philadelphia Sites. It serves as a standardized incident reporting template that contractors would need to use in the event of any mishaps during contract performance.
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Text version
NAVFAC INITIAL MISHAP NOTIFICATION
1) Name of activity and exact location where mishap occurred:
2) Type of work being performed (If contract, type of contract):
3) Date and Time of Mishap:
4) Brief description of mishap, extent of injuries and summary of initial lessons learned:
5) Initial corrective actions and indication if and when follow up information will be provided:
6) Extent of property damage if applicable:
7) Safety investigator assigned if known at this time:
8) Employee immediate supervisor or responsible person:
9) Mishap Review Board anticipated date:
NAVY CIVILIAN CONTRACTOR MILITARY
william.j.garrett Stamp
NAVFAC INITIAL MISHAP NOTIFICATION & LESSONS LEARNED DISTRIBUTION PROCESS
AKASHIH
D:20070328091318+09'00' D:20070328091321+09'00'
NAVFAC INITIAL MISHAP NOTIFICATION
1) Name of activity and exact location where mishap occurred:
2) Type of work being performed (If contract, type of contract):
3) Date and Time of Mishap:
4) Brief description of mishap, extent of injuries and summary of initial lessons learned:
5) Initial corrective actions and indication if and when follow up information will be provided:
6) Extent of property damage if applicable:
7) Safety investigator assigned if known at this time:
8) Employee immediate supervisor or responsible person:
9) Mishap Review Board anticipated date:
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