SupervisoryMishapReport.pdf

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PDF (DLA)

DLA FORM 1591, AUG 2007

SUPERVISORY MISHAP REPORT

Page of

PREVIOUS EDITION IS OBSOLETE

PDF (DLA)

DLA FORM 1591, AUG 2007

Page of

SUPERVISORY MISHAP REPORT

PRIVACY ACT STATEMENT

Information is collected to comply with regulatory reporting requirements. Details about the accident site will be used to identify and correct known or potential hazards and to formulate improved accident prevention programs. The data, with all personal identifiers removed, may be used to prepare statistical reports.

10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 29 U.S.C. 651 et seq., The Occupational Safety and Health Act of 1970 (OSHA); E.O. 12196, Occupational Safety and Health Programs for Federal Employees; 29 CFR 1960, Subpart I, Record keeping and Reporting Requirements for Federal Occupational Safety and Health Programs; DoD Instruction 6055.1, DoD Safety and Occupational Health (SOH) Program; and E.O. 9397 (SSN).

Data may be provided to the Department of Labor to comply with the requirement to report Federal civilian employee on-the-job accidents (29 CFR part 1960). Data may also be provided under any of the DoD “Blanket Routine Uses” published at http://www.dod.mil/privacy/notices/blanket-uses.html .

Voluntary; however, failure to provide the requested data may result in our inability to comply with reporting requirements or to identify and correct workplace hazards.

Rules for collecting, using, retaining, and safeguarding this information are contained in DLA Privacy Act Systems Notice S600.30, entitled "Safety, Health, Injury, and Accident Records" available at http://www.dod.mil/privacy/notices/dla .

Purpose:

Authority:

Routine Uses:

Disclosure:

Rules of Use:

PREVIOUS EDITION IS OBSOLETE

5. MISHAP CASE CLASSIFICATION (Check appropriate classification)

20. EMPLOYEE WAS WORKING OVERTIME:

21. PERSONNEL TYPE:

22. WHAT WAS THE SINGLE MOST SEVERE INJURY/ILLNESS TO THIS EMPLOYEE:

23. WHAT PART OF THE BODY RECEIVED THE MOST SEVERE INJURY:

Part of Body #1

INFORMATION ABOUT VEHICLE(S) AND EQUIPMENT THAT WERE INVOLVED IN THE ACCIDENT

40. Year

41. Make

42. Model

43. State & License #

44. Vehicle Identification/Serial Number

45. Licensed Driver?

46. Were Seatbelts Used?

#2

SUPERVISORY REVIEW

SAFETY AND HEALTH REVIEW

MANAGEMENT REVIEW

INSTRUCTIONAL NOTES

Block 5 - If the classification of the mishap changes after the report submission it is the supervisor/manager's responsibility to notify the DLA Safety and Health Manager to which the report is submitted, e.g. Same Day Clinic Visit or No Treatment to Lost Time, etc.

Block 12 - FNN is Foreign National Number. This is the local national employee number provided to foreign national employees.

Blocks 16 & 28 - AF Europe is defined as Armed Forces Europe and AP Pacific is the Armed Forces Pacific.

Block 21 - There are several personnel types (i.e. civilian, military, foreign national -- direct hire and indirect hire, contractor -- supervised and non-supervised, and non appropriated fund). DLA Form 1591 is used to track mishaps in all categories listed whether a supervised contractor or a non-supervised contractor; or whether a direct hire foreign national or indirect hire. For clarification, OSHA Compliance Directive CPL 2-0.131, Frequently Asked Questions #31-1 defines "supervised" as "Day-to-day supervision occurs when in addition to specifying the output, product or result to be accomplished by the person's work, the employer supervises the details, means, methods and processes by which the work is to be accomplished."

Block 22 - Describe the extent of injury/illness in Block 37.

Block 33 - Restrictive duty means that the employee was unable to perform all the tasks that they normally do at least once a week.

Supervisory Mishap Report DLA Form 1591, August 2006 DLAForms@dla.mil DLA Forms

DES-E

Joyce Bellamy, 703-767-6239 Lori Sprouse, 703-767-6245 One Book Chapter - Safety

YES

No August 2007