Attachment_J15_MCSC_Mishap_Form_OSHA_form_300_or_equivalent-1.0.pdf
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- Attached to
- MAGTF Training Systems Support
- Solicitation number
- M6785418R7800
- Issued by
-
United States Marine Corps
About this file
This document contains a mishap report form and details of a related federal contract opportunity for MAGTF Training Systems Support. The mishap report form collects information about injuries, property damage, witnesses, circumstances, corrective actions, and signatures from supervisors and safety officers. The federal contract opportunity is a draft solicitation from the United States Marine Corps seeking proposals to support standardized training for the Marine Air-Ground Task Force through leveraging innovative simulation technologies and existing acquisition programs. Questions regarding the opportunity must be sent to the identified point of contact by the specified due date, with no phone calls accepted. The effort aims to increase individual and unit skill levels through repetitive and realistic training simulations.
Attachment J15
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Text version
PERSON INVOLVED IN MISHAP SIGN BELOW
SUPERVISOR SIGN BELOW
UNIT SAFETY OFFICER SIGN BELOW
COMMANDING OFFICER/DIVISION DIRECTOR SIGN BELOW
| MCSC Mishap and Near Miss Report-page1 |
| MCSC Mishap and Near Miss Report-page2 |
| 1 INJURED PERSON OR PERSON INVOLVED IN NEAR MISS Last Name First MIJ: |
| 2 AGE: |
| 3 SEX: |
| 4 PAY GRADE: |
| 5 MOSOCCUPATIONTRADE: |
| 6 TRAININGCERTIFICATION: |
| 7 COMPONENT: |
| 8 JOB ASSIGNMENT: |
| 9 YEARS OF EXPERIENCE: |
| 10 REPORTING ACTIVITYUNIT Command Division etc: |
| 11 DUTY STATION: |
| 13 DATE OF INJURYINCIDENT: |
| 14 DAY OF WEEK: |
| 15 HOUR OF DAY: |
| 16 DUTY STATUS AttimeotmishapJ: |
| 17 DATE RETURNED TO WORK: |
| 18 NO WORKDAYS LOST: |
| 19 NO LIGHT DUTY DAYS: |
| 20 NO DAYS HOSPITALIZED: |
| 22 ASSIGNED WORKPLACE Occupational mishaps only: |
| 23 WITNESS Name Address and Telephone Number: |
| 24 D ESC Rl PTI ON 0 F MIS HAPINCIDENT Describe circumstances and events who what when where why and how leading to the mishapnear miss in sufficient detail that reviewing authorities may gain a complete understanding of cause and effect relationships If more space is needed use a blank sheet of paper and attach to this form: |
| 25 EVENTEXPOSURE Describe How injurynear miss occurred eg struck by fall etc: |
| 26 TYPE OF INJURY CuVLaceration BruiseContusion etc: |
| 27 BODY PART INJURED Right Arm Lett Leg etc: |
| 28 WEATHER CONDITION: |
| 29 UNSAFE PERSONAL FACTOR Speeding looked away etc: |
| 30 PERSONAL PROTECTIVE EQUIPMENT REQUIRED: |
| 31 PERSONAL PROTECTIVE EQUIPMENT UTILIZED: |
| 32 DOD PROPERTY EQUIPMENT DAMAGED: |
| 33 NONDOD PROPERTY EQUIPMENT DAMAGED: |
| 34 TOTAL COST PROPERTY DAMAGED: |
| 35 TOTAL INJURY COST It known: |
| 36 UNSAFE ACT Act directly contributing to mishap: |
| 37 UNSAFEHAZARDOUS CONDITION Unsafe condition of objects or environment: |
| 39 CORRECTIVE ACTION TAKEN DescribeRow1: |
| 47 TITLE GRADE AND TELEPHONE NUMBER: |
| 48 DATE: |
| 50 TITLE GRADE AND TELEPHONE NUMBER: |
| 51 DATE: |
| Fatality: Off |
| Permanent Total Disability: Off |
| Injury: Off |
| Permanent Partial Disability: Off |
| Occupational Illness: Off |
| Near Miss: Off |
| Property Damage: Off |
| On Base: Off |
| Off Base: Off |
| 44 TITLE GRADE AND TELEPHONE NUMBER: |
| 41 TITLE GRADE AND TELEPHONE NUMBER: |
| 42 DATE: |
| 45 DATE: |
| Not yet determined, pending completion of investigation: Off |
| Determined (list cause): Off |
| Mishap involved a failure to control a previously identified hazard: Off |
| Place of Occurrence: |
File details come from the government source that posted it. Updated .