J_10Appendix C- Accident ad Mishap Report AF From 37.pdf
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This is a Preliminary Mishap Report form used by Joint Base McGuire-Dix-Lakehurst to document and investigate workplace incidents involving military or civilian personnel. The form (JBMDL Form 37) is designed to capture comprehensive information about mishaps occurring on or off base, including personnel data, vehicle/equipment information, incident description, and corrective actions.
The form collects personal data on the affected individual including name, rank, AFSC/job series, age, sex, unit assignment, duty status (on or off duty), and mishap location (on or off base). It requires documentation of the specific job task or activity being performed, description of injury with body part affected, and workdays lost due to hospitalization or quarters. The Vehicle/Equipment Data section captures manufacturer, make/model, registration or serial numbers, year, USAF property status, description, damage assessment, repair hours required, and material costs. The Synopsis section requires a detailed narrative description of events leading to the mishap and explanation of root causes, along with corrective actions taken or recommended by supervisory or higher-level personnel to prevent recurrence. The Certification section documents supervisor review and unit commander approval. The form includes instructions for completing each of the 37 items, with examples provided for clarification on how to document specific information such as job tasks, injury types, equipment damage, and preventive measures.
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JOINT BASE MCGUIRE-DIX-LAKEHURST MISHAP REPORT
FOR OFFICIAL USE ONLY WHEN FILLED IN SEE REVERSE FOR INSTRUCTIONS
PERSONAL DATA
1. Mishap Date
2. Mishap Time
3. Name (Last, First’ MI)
4. Rank
5. AFSC 6. Age 7. Sex
8. Unit
9. Duty phone
10. PPE type
11. Duty Status (Check One)
On Duty Off Duty
12. Mishap Location (Check One)
On Base Off |Base
13. Job/Task or Activity
14. Description of Injury
15. Workdays Lost
Hospital___________ Quarters____________
VEHICLE/EQUIPMENT DATA
16. Manufacture
17. Make/Model 18. Lic/Reg/Serial/Tail Number 19. year 20. USAF Property
Yes No
21. Description
22. PPE Used
Yes No
23. PPE Type 24. Damage Description 25. Repair Hours 26. Material Cost
SYNOPSIS
27. DESCRIPTION OF EVENTS THAT RESULTED IN MISHAP (Continue on reverse in necessary)
28. CORRECTIVE ACTION TAKEN TO PREVENT RECURRENCE
CERTIFICATION
29. Supervisor’s Name
30. Rank
31. Duty Phone
32. Unit Safety Review 33. Unit Commanders Signature
WING SAFETY USE ONLY
34. Date Received
35. Reviewing Person 37 Notes/Memo
JBMDL FORM 37,
JBMDL 37 (Previous form is obsolete)
INSTRUCTIONS FOR COMPLETING PRELIMINARY MISHAP REPORT
PERSONNEL DATA
ITEM
1. Date mishap occurred.
2. Time mishap occurred. If unknown provide estimated time.
3. Self-explanatory.
4. Military rank or civilian pay grade.
5. Military AFSC or civilian job series number.
6. Age of person injured/involved at time of the mishap.
7. Indicate M (male) or F (female).
8. Unit to which individual was assigned at the time of the mishap.
9. Duty phone of the individual being reported.
10. Personal protective equipment
11. Check the appropriate duty status.
12. Check on base or off base and indicate the specific location (Bldg. 1234, CES Carpenter Shop, Highway 38 near Mt Holly).
13. Indicate job task or activity in which the person was involved at the time of the mishap (operating table saw, playing basketball, etc.).
14. Describe specific injury and part of body injured (fractured left leg, lacerated right index finger, etc.).
15. Indicate number of days hospitalized or placed on quarters in the appropriate space.
VEHICLE/EQUIPMENT DATA
16. Indicate manufacturer of vehicle or equipment (Ford, Black & Decker, Boeing, etc.).
17. Indicate make or model of vehicle or equipment (Bronco, B-4, C-141, etc.).
18. Indicate license number of POV’s reg. number for AF motor vehicles, serial number for equipment, and tail number of aircraft.
19. Self-explanatory.
20. Self-explanatory.
21. Describe vehicle or equipment (4 door sedan, maintenance stand, drill press, etc.).
22. Indicate whether personal protective equipment (PPE) was used for the task activity performed.
23. Indicate the type of PPE required for the task or activity (seat belts, steel-toed shoes, etc.).
24. Describe the damage to the vehicle or the equipment (dent to front left quarter panel, punctured fuel tank, etc.).
25. Indicate man-hours required to repair damaged vehicles or equipment.
26. Indicate the cost of materials required to repair the damaged vehicle or equipment.
27. Describe the events that resulted in the mishap. Explain why this mishap occurred.
28. State the corrective action taken by supervisory or higher level within the unit to prevent future similar mishaps.
29 through 37 self-explanatory.
Item 27 (continued)
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