J-0200000-05(b)_Initial_Contractor_Mishap_Notification_Report.pdf

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Attached to
L'ENFANT SHUTTLE SERVICES Federal contract opportunity
Solicitation number
N4008019R0311
Issued by
Department of the Navy Naval Facilities Engineering Command

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Initial Contractor Mishap Notification Report

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INITIAL CONTRACTOR MISHAP

NOTIFICATION REPORT

CIVILIAN MILITARY CONTRACTOR

1. NAME OF ACTIVITY, INSTALLATION, OR LOCATION WHERE

INCIDENT OCCURRED:

2. TYPE OF WORK BEING PERFORMED:

3. DATE AND TIME OF INCIDENT:

4. CORRECTIVE ACTION AT INITIAL NOTIFICATION AND WHEN FOLLOW UP WILL BE PROVIDED:

5. EXTENT OF PROPERTY DAMAGE:

7. NAME OF CONTRACTOR6. SAFETY INVESTIGATORS:

8. NAME AND NUMBER OF CONTRACT:

9. NAME OF INJURED PERSONNEL

12. THE INITIAL LESSONS LEARNED INCLUDE:

10. EXTENT OF INJURIES

11. BRIEF DESCRIPTION OF THE INCIDENT:

Microsoft Word - MISHAP Form.doc nora.tabafunda D:20061122152122- 08'00' D:20081021130938- 04'00'

INITIAL CONTRACTOR MISHAP

NOTIFICATION REPORT

CIVILIAN MILITARY CONTRACTOR

1. NAME OF ACTIVITY, INSTALLATION, OR LOCATION WHERE

INCIDENT OCCURRED:

2. TYPE OF WORK BEING PERFORMED:

3. DATE AND TIME OF INCIDENT:

4. CORRECTIVE ACTION AT INITIAL NOTIFICATION AND WHEN FOLLOW UP WILL BE PROVIDED:

5. EXTENT OF PROPERTY DAMAGE:

7. NAME OF CONTRACTOR

6. SAFETY INVESTIGATORS:

8. NAME AND NUMBER OF CONTRACT:

9. NAME OF INJURED PERSONNEL

12. THE INITIAL LESSONS LEARNED INCLUDE:

10. EXTENT OF INJURIES

11. BRIEF DESCRIPTION OF THE INCIDENT:

CIV:
MIL:
CONT:
NAME_OF_ACTIVITY:
DATE___TIME:
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x9:
x3:
x5:
x6:
x8:
x7:
LESSON:
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