The file's text, extracted by GovTribe without its formatting.
Main
Contractor Injury/Mishap Report and/or Property Damage
| All Blocks Are Required | Key | | Drop Down Menu | | Auto Populated |
| 1 | POC Email Address | | | |
| 2 | COR Email Address | | | |
| 3 | Today's Date | | | |
| 4 | Mishap Date | | | |
| 5 | UIC | | | |
| Enter Valid UIC in Block 5 | 6 | Brigade | | | |
| Enter Valid UIC in Block 5 | 7 | Battalion | | | |
| Enter Valid UIC in Block 5 | 8 | LRC | | | |
| 9 | Where Exactly Did This Accident/Mishap Occur? | | | |
| 10 | Accident Type | | | |
| 11 | Accident Context | | | |
| 12 | Category | | | |
| 13 | Days in Hospital In-Patient | | | |
| 14 | Days of Lost Time | | | |
| 15 | Days of Restricted Work | | | |
| Abrassions | 16 | Injury/Illness Type | | | |
| 17 | Cause of Injury | | | |
| 18 | Body Area | | | |
| 19 | Specific Body Part | | | |
| 20 | Attributable Factor | | | |
| 21 | If Human Error | | | |
| 22 | What Was Damaged | | | |
| 23 | Estimated Cost of Damage | | | |
| 24 | | | Who/What was Injured/Damaged | |
| | | | What happened | |
| | Narrative | | Where did this occur | |
| | | | When did this happen | |
| | | | Why did this happen | |
| 25 | Corrective Actions Taken or Will Take To Prevent This From Happening Again | | | |
| UIC Table Start | | | |
| W0DAAA | HQ ASC | HHC | N/A |
| W0DA6B | HQ ASC | JPPSO-MA | N/A |
| W0DA4G | HQ ASC | JPPSO-NW | N/A |
| WJN799 | 401 | N/A | N/A |
| W0DA49 | 401 | AFSBn Qatar | N/A |
| W0DA51 | 401 | AFSBn Kuwait | N/A |
| W0DAG7 | 401 | AFSBn-SWA WEB Kuwait | N/A |
| W0DAH7 | 401 | AFSBn-Afghanistan | N/A |
| W0DA55 | 401 | AFSBn SWA | N/A |
| WJN899 | 402 | N/A | N/A |
| W6XPAA | 402 | AFSBn HAWAII | N/A |
| W6XP01 | 402 | N/A | LRC Hilo (PTA) |
| W6XSAA | 402 | AFSBn ALASKA (LRC JBER) | N/A |
| W6XS01 | 402 | N/A | LRC GREELY |
| W6XS02 | 402 | N/A | LRC WAINWRIGHT |
| WJN999 | 403 | N/A | N/A |
| W6XGAA | 403 | N/A | LRC Daegu |
| W6XHAA | 403 | AFSBn Korea | N/A |
| W6XH01 | 403 | N/A | LRC Yongsan |
| W6XH02 | 403 | N/A | LRC Red Cloud |
| W6XJAA | 403 | N/A | LRC Camp Zama |
| W6XKAA | 403 | N/A | LRC Torii Station |
| W0DA52 | 403 | AFSBn NEA | N/A |
| W0DAC6 | 403 | AFSBn NEA FWD WEB YOKOHAMA | N/A |
| W0DA53 | 403 | AFSBn NEA FWD/LST SAGAMI | N/A |
| WJP199 | 404 | N/A | N/A |
| W6WTAA | 404 | N/A | LRC Aberdeen Proving Ground (& EA) |
| W6X8AA | 404 | N/A | LRC Adelphi |
| W6WRAA | 404 | N/A | LRC Detroit Arsenal |
| W6XCAA | 404 | N/A | LRC Devens |
| W6XFAA | 404 | N/A | LRC Hunter Liggett |
| W6XRAA | 404 | N/A | LRC Irwin |
| W6X9AA | 404 | N/A | LRC McCoy |
| W6WVAA | 404 | N/A | LRC Natick (Soldier Support Center) |
| W6WUAA | 404 | N/A | LRC Picatinny Arsenal |
| W6YFAA | 404 | N/A | LRC Polk |
| W6WQAA | 404 | N/A | LRC Redstone Arsenal |
| W6WSAA | 404 | N/A | LRC Rock Island Arsenal |
| W6XBAA | 404 | N/A | LRC JB McGuire-Dix |
| W6YXAA | 404 | N/A | LRC JB Lewis McChord (JBLM) |
| W6YX01 | 404 | N/A | LRC Yakima Training Center |
| W0DA30 | 404 | AFSBn CHARLESTON (ASLAC) | N/A |
| WJP299 | 405 | N/A | N/A |
| W6XUAA | 405 | N/A | BASOPS |
| W6Y8AA | 405 | N/A | LRC Ansbach |
| W6Y0AA | 405 | N/A | LRC Baumholder |
| W6Y1AA | 405 | N/A | LRC Bavaria (Graf) |
| W6XVAA | 405 | N/A | LRC Benelux |
| W6XWAA | 405 | N/A | LRC Brussels |
| W6Y3AA | 405 | N/A | LRC Garmisch |
| W6Y4AA | 405 | N/A | LRC Hohenfels |
| W6Y5AA | 405 | N/A | LRC Italy (Vicenza) |
| W6Y6AA | 405 | N/A | LRC Livorno |
| W6XZAA | 405 | N/A | LRC Rheinland Pfalz (Ktown) |
| W6XXAA | 405 | N/A | LRC Schinnen |
| W6XYAA | 405 | N/A | LRC Stuttgart |
| W6Y7AA | 405 | N/A | LRC Wiesbaden |
| W0DAN5 | 405 | AFSBn Germany | N/A |
| W0DAP4 | 405 | BLSE CAB 12 ID KATTERB | N/A |
| W0DAC9 | 405 | BLSE SBCT 2ND CR VILSECK | N/A |
| W0DA45 | 405 | AFSBn Africa | N/A |
| W0DAB6 | 405 | LST Africa | N/A |
| W0DAV8 | 405 | BLSE 173RD VICENZA | N/A |
| W0DA24 | 405 | AFSBn Benelux (Eygelshoven) | N/A |
| W0DA8M | 405 | APS 2 Zutendaal | N/A |
| W0DA88 | 405 | APS 2 Dulmen | N/A |
| W0DAN6 | 405 | AFSBn Mannheim | N/A |
| WJP399 | 406 | N/A | N/A |
| W6WXAA | 406 | N/A | LRC AP Hill |
| W6WWAA | 406 | N/A | LRC Belvoir |
| W6YGAA | 406 | N/A | LRC Benning |
| W6X2AA | 406 | N/A | LRC Carlisle Barracks |
| W6WYAA | 406 | N/A | LRC Detrick |
| W6YHAA | 406 | N/A | LRC Gordon |
| W6XAAA | 406 | N/A | LRC Hamilton |
| W6YMAA | 406 | N/A | LRC Jackson |
| W6YCAA | 406 | N/A | LRC Lee |
| W6WZAA | 406 | N/A | LRC Meade |
| W6YJAA | 406 | N/A | LRC Rucker |
| W6X1AA | 406 | N/A | LRC West Point |
| W6YLAA | 406 | N/A | LRC Hunter Army Airfield |
| W6YNAA | 406 | N/A | LRC Joint Base Langley-Eustis |
| W6X0AA | 406 | N/A | LRC Joint Base Myer-HH |
| W6YBAA | 406 | AFSBn Bragg | N/A |
| W6YDAA | 406 | AFSBn Campbell | N/A |
| W6YEAA | 406 | AFSBn Drum | N/A |
| W6YKAA | 406 | AFSBn Stewart | N/A |
| WJP499 | 407 | N/A | N/A |
| W6XDAA | 407 | N/A | LRC Buchanan |
| W6YVAA | 407 | N/A | LRC Knox |
| W6YTAA | 407 | N/A | LRC Leonard Wood |
| W6X3AA | 407 | N/A | LRC Leavenworth |
| W6XEAA | 407 | N/A | LRC Miami |
| W6YWAA | 407 | N/A | LRC Sill |
| W6YSAA | 407 | N/A | LRC JB San Antonio |
| W6YS01 | 407 | N/A | LRC SotoCano |
| W6X5AA | 407 | N/A | LRC White Sands Missile Range |
| W6X4AA | 407 | N/A | LRC Presidio |
| W6X6AA | 407 | N/A | LRC Yuma Proving Ground |
| W6X7AA | 407 | N/A | LRC Dugway Proving Ground |
| W6XQAA | 407 | N/A | LRC Huachuca |
| W6YPAA | 407 | AFSBn Bliss | N/A |
| W6YQAA | 407 | AFSBn Carson | N/A |
| W6YRAA | 407 | AFSBn Hood | N/A |
| W6YUAA | 407 | AFSBn Riley | N/A |
| UIC Table End | | | |
| Accident Type Start | | | |
| Property Damage | | | |
| Fatality | | | |
| Injury/Illness That Causes 1 Day Away From Work or More Past Occurance | | | |
| Injury/Illness That Causes Work Restriction/Job Transfer | | | |
| Contaminated Needle Stick/Sharp | | | |
| Work Related Turbuculosis | | | |
| Medical Treatment Beyond First Aid | | | |
| Occupational Hearing Loss | | | |
| First Aid Only | | | |
| Near Miss | | | |
| Accident Type End |
| Accident Context Start |
| Maintenance |
| Warehouse |
| Shop Floor |
| Dining Facility |
| Army Tactical Vehicle |
| Non-Tactical Vehicle |
| Private Motor Vehicle |
| Material Handeling Equipment |
| Pedestrian |
| Railhead |
| Watercraft |
| N/A |
| Accident Context End |
| Category Start |
| Exposure |
| Vehicular |
| Other |
| Caught In/Under/Between-Struck By/Against |
| Slip/Trip/Fall |
| Bodily Reaction |
| Category End |
| Injury/Illness Type Start |
| Abrassions |
| Amputation - No Bone |
| Amputation - With Bone |
| Asphyxiation |
| Burns (Chemical) |
| Burns (Thermal) |
| Decompression Sickness (Bends) |
| Contusion |
| Concussion |
| Cuts/Laceration |
| Dislocation |
| Fractures |
| Frostbite |
| Heat Exhaustion |
| Heatstroke |
| Hernia/Rupture |
| Loss of Consciousness |
| Noise Injury |
| Puncture Wound |
| Rash |
| Sprains/Strains |
| Swelling |
| N/A |
| Injury/Illness Type End |
| Cuse of Injury Start |
| Bodily Reaction |
| Caught In/Under/Between |
| Exposure |
| External Contact |
| Fell From Elevation |
| Fell From Same Level |
| Ingested |
| Inhaled |
| Occupational Illness/Injury |
| Overexertion |
| Rubbed/Abbraded |
| Struck Against |
| Struck By |
| Thrown From |
| N/A |
| Cause of Injury End | | | | | | | |
| Body Area Start | | | | | | | |
| Area | Body | Head | Neck | Upper | Trunk | Lower | N/A |
| Body | General | General | General | General | General | General | N/A |
| Head | | Ear(s) | Throat | Shoulder(s) | Chest | Hip(s) | |
| Neck | | Eye(s) | | Arm(s) | Heart | Thigh(s) | |
| Upper | | Face | | Elbow(s) | Abdominal | Leg(s) | |
| Trunk | | Forehead | | Wrist(s) | Back | Knee(s) | |
| Lower | | General | | Hand(s) | | Shin(s) | |
| N/A | | Jaw | | Finger(s) | | Calve(s) | |
| | Nose | | | | Ankle(s) | |
| | | | | | Foot/Feet | |
| | | | | | Toe(s) | |
| Body Area End | | | | |
| Attributable Factor Start | | | | |
| Fact | Environmental | Materiel | HumanError | N/A |
| Environmental | N/A | N/A | Complacency | N/A |
| Materiel | | | Over-Confident | |
| HumanError | | | Unsupervised | |
| N/A | | | Undisciplined | |
| | | Untrained | |
| Attributable Factor End |
| GFE/GFF Start |
| Government Furnished Equipment |
| Government Furnished Facility |
| Other |
| N/A |
GFE/GFF End